PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX COST REPORT WORKSHEET S CERTIFICATION AND SETTLEMENT SUMMARY PARTS I & II INTERMEDIARY [ ] AUDITED DATE RECEIVED ________ [ XX ] INITIAL [ ] RE-OPENING USE ONLY: [ ] DESK REVIEWED INTERMEDIARY NO. ________ [ ] FINAL [ XX ] MCR CODE 1 PART I - CERTIFICATION CHECK XX ELECTRONICALLY FILED COST REPORT DATE: 05/29/2009 APPLICABLE BOX __ MANUALLY SUBMITTED COST REPORT TIME: 10:18_____ MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WHERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT. CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S) I HEREBY CERTIFY THAT I HAVE READ THE ABOVE STATEMENT AND THAT I HAVE EXAMINED THE ACCOMPANYING ELECTRONICALLY FILED OR MANUALLY SUBMITTED COST REPORT AND THE BALANCE SHEET AND STATEMENT OF REVENUE AND EXPENSES PREPARED BY COMMUNITY HOSPTAL OF NOBLE COUNTY, INC. (15-0146) (PROVIDER NAME(S) AND NUMBER(S)) FOR THE COST REPORTING PERIOD BEGINNING 01/01/2008 AND ENDING 12/31/2008, AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT IS A TRUE, CORRECT AND COMPLETE STATEMENT PREPARED FROM THE BOOKS AND RECORDS OF THE PROVIDER IN ACCORDANCE WITH APPLICABLE INSTRUCTIONS, EXCEPT AS NOTED. I FURTHER CERTIFY THAT I AM FAMILIAR WITH THE LAWS AND REGULATIONS REGARDING THE PROVISION OF HEALTH CARE SERVICES AND THAT THE SERVICES IDENTIFIED IN THIS COST REPORT WERE PROVIDED IN COMPLIANCE WITH SUCH LAWS AND REGULATIONS. (SIGNED) __________________________________________________ OFFICER OR ADMINISTRATOR OF PROVIDER(S) __________________________________________________ TITLE __________________________________________________ DATE PART II - SETTLEMENT SUMMARY TITLE V TITLE XVIII TITLE XIX PART A PART B 1 2 3 4 1 HOSPITAL 192917 -273167 1 2 SUBPROVIDER I 2 3 SWING BED - SNF 3 4 SWING BED - NF 4 5 SKILLED NURSING FACILITY 5 6 NURSING FACILITY 6 7 HOME HEALTH AGENCY 7 8 OUTPATIENT REHABILITATION PROVIDER 8 9 HEALTH CLINIC 9 100 TOTAL 192917 -273167 100 THE ABOVE AMOUNTS REPRESENT 'DUE TO' OR 'DUE FROM' THE APPLICABLE PROGRAM FOR THE ELEMENT OF THE ABOVE COMPLEX INDICATED. ACCORDING TO THE PAPERWORK REDUCTION ACT OF 1995, NO PERSONS ARE REQUIRED TO RESPOND TO A COLLECTION OF INFORMATION UNLESS IT DISPLAYS A VALID OMD CONTROL NUMBER. THE VALID OMB CONTROL NUMBER FOR THIS INFORMATION COLLECTION IS 0938-0050. THE TIME REQUIRED TO COMPLETE THIS INFORMATION COLLECTION IS ESTIMATED 657 HOURS PER RESPONSE, INCLUDING THE TIME TO REVIEW INSTRUCTIONS, SEARCH EXISTING RESOURCES, GATHER THE DATA NEEDED, AND COMPLETE AND REVIEW THE INFORMATION COLLECTION. IF YOU HAVE ANY COMMENTS CONCERNING THE ACCURACY OF THE TIME ESTIMATE(S) OR SUGGESTIONS FOR IMPROVING THIS FORM, PLEASE WRITE TO: HEALTH CARE FINANCING ADMINISTRATION, 7500 SECURITY BOULEVARD, N2-14-26, BALTIMORE, MARYLAND 21244-1850, AND TO THE OFFICE OF THE INFORMATION AND REGULATORY AFFAIRS, OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, D.C. 20503. PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/29/2009 10:18 HOSPITAL AND HEALTH CARE COMPLEX IDENTIFICATION DATA WORKSHEET S-2 HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX ADDRESS: 1 STREET: 401 SAWYER ROAD P.O.BOX: P.O. BOX 728 1 1.01 CITY: KENDALLVILLE STATE: IN ZIP CODE: 46755-0728 COUNTY: NOBLE 1.01 HOSPITAL AND HOSPITAL-BASED COMPONENT IDENTIFICATION: PAYMENT SYSTEM PROVIDER DATE (P,T,O OR N) COMPONENT COMPONENT NAME NUMBER CERTIFIED V XVIII XIX 0 1 2 3 4 5 6 2 HOSPITAL COMMUNITY HOSPTAL OF NOBLE COUNTY, 15-0146 05/30/2000 N P P 2 3 SUBPROVIDER I 3 4 SWING BEDS - SNF 4 5 SWING BEDS - NF 5 6 HOSPITAL-BASED SNF 6 7 HOSPITAL-BASED NF 7 8 HOSPITAL-BASED OLTC 8 9 HOSPITAL-BASED HHA 9 11 SEPARATELY CERTIFIED ASC 11 12 HOSPITAL-BASED HOSPICE 12 14 HOSP-BASED RHC 14 15 OUTPATIENT REHABILITATION PROVID 15 16 RENAL DIALYSIS 16 17 COST REPORTING PERIOD (MM/DD/YYYY) FROM: 01/01/2008 TO: 12/31/2008 17 1 2 18 TYPE OF CONTROL 2 18 TYPE OF HOSPITAL/SUBPROVIDER 19 HOSPITAL 1 19 20 SUBPROVIDER I 20 OTHER INFORMATION 21 INDICATE IF YOUR HOSPITAL IS EITHER (1) URBAN OR (2) RURAL AT THE END OF THE 21 COST REPORTING PERIOD IN COLUMN 1. IF YOUR HOSPITAL IS GEOGRAPHICALLY CLASSIFIED OR LOCATED IN A RURAL AREA, IS YOUR BED SIZE IN ACCORDANCE WITH CFR 42 412.105 LESS THAN OR EQUAL TO 100 BEDS, ENTER IN COLUMN 2 'Y' FOR YES OR 'N' FOR NO. 21.01 DOES YOUR FACILITY QUALIFY AND IS CURRENTLY RECEIVING PAYMENT FOR YES 21.01 DISPROPORTIONATE SHARE IN ACCORDANCE WITH 42 CFR 412.106? 21.02 HAS YOUR FACILITY RECEIVED GEOGRAPHIC RECLASSIFICATION? ENTER 'Y' FOR YES 21.02 AND 'N' FOR NO. IF YES, REPORT IN COLUMN 2 THE EFFECTIVE DATE. 21.03 ENTER IN COLUMN 1 YOUR GEOGRAPHIC LOCATION EITHER (1) URBAN (2) RURAL. IF YOU ANSWERED 2 Y 21.03 URBAN IN COLUMN 1 INDICATE IF YOU RECEIVED EITHER A WAGE OR STANDARD GEOGRAPHIC RECLASSIFICATION TO A RURAL LOCATION, ENTER IN COLUMN 2 'Y' AND 'N' FOR NO. IF COLUMN 2 IS YES, ENTER IN COLUMN 3 THE EFFECTIVE DATE (mm/dd/yyyy)(SEE INSTRUCTION). DOES YOUR FACILITY CONTAIN 100 OR FEWER BEDS IN ACCORDANCE WITH 42 CFR 412.105? ENTER IN COLUMN 4 'Y' FOR YES AND 'N' FOR NO. ENTER IN COLUMN 5 THE PROVIDERS ACTUAL MSA OR CBSA. 21.04 FOR STANDARD GEOGRAPHIC RECLASSIFICATION (NOT WAGE), WHAT IS YOUR STATUS AT THE BEGINNING 2 21.04 OF THE COST REPORTING PERIOD. ENTER (1) URBAN AND (2) RURAL. 21.05 FOR STANDARD GEOGRAPHIC RECLASSIFICATION (NOT WAGE), WHAT IS YOUR STATUS AT THE END OF THE 2 21.05 COST REPORTING PERIOD. ENTER (1) URBAN AND (2) RURAL. 21.06 DOES THIS HOSPITAL QUALIFY FOR THE THREE-YEAR TRANSITION OF HOLD HARMLESS PAYMENTS FOR A YES 21.06 SMALL RURAL HOSPITAL UNDER THE PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT SERVICES UNDER DRA SECTION 5105? ENTER 'Y' FOR YES AND 'N' FOR NO. 22 ARE YOU CLASSIFIED AS A REFERRAL CENTER? NO 22 23 DOES THIS FACILITY OPERATE A TRANSPLANT CENTER? IF YES, ENTER CERTIFICATION DATE(S) BELOW NO 23 23.01 IF THIS IS A MEDICARE CERTIFIED KIDNEY TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE 23.01 IN COL. 2 AND TERMINATION IN COl. 3. 23.02 IF THIS IS A MEDICARE CERTIFIED HEART TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE 23.02 IN COL. 2 AND TERMINATION IN COL. 3. 23.03 IF THIS IS A MEDICARE CERTIFIED LIVER TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE 23.03 IN COL. 2 AND TERMINATION IN COL. 3. 23.04 IF THIS IS A MEDICARE CERTIFIED LUNG TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE 23.04 IN COL. 2 AND TERMINATION IN COL. 3. 23.05 IF MEDICARE PANCREAS TRANSPLANTS ARE PERFORMED SEE INSTRUCTIONS FOR ENTERING CERTIFICATION 23.05 AND TERMINATION DATE. 23.06 IF THIS IS A MEDICARE CERTIFIED INTESTINAL TRANSPLANT CENTER, ENTER THE CERTIFICATION 23.06 DATE IN COL. 2 AND TERMINATION IN COL. 3. 23.07 IF THIS IS A MEDICARE CERTIFIED ISLET TRANSPLANT CENTER ENTER THE CERTIFICATION DATE 23.07 IN COL. 2 AND TERMINATION IN COL. 3. 24 IF THIS AN ORGAN PROCUREMENT ORGANIZATION (OPO), ENTER THE OPO NUMBER IN COL 2. 24 AND TERMINATION IN COL. 3. 24.01 IF THIS A MEDICARE TRANSPLANT CENTER; ENTER THE CCN (PROVIDER NUMBER) IN COL 2, THE 24.01 CERTIFICATION DATE OR RECERTIFICATION DATE (AFTER DECEMBER 26, 2007) IN COL 3. 25 IS THIS A TEACHING HOSPITAL OR AFFILIATED WITH A TEACHING HOSPITAL AND YOU ARE MAKING NO 25 PAYMENTS FOR I & R? 25.01 IS THIS TEACHING PROGRAM APPROVED IN ACCORDANCE WITH CMS PUB. 15-I, CHAPTER 4? NO 25.01 25.02 IF LINE 25.01 IS YES, WAS MEDICARE PARTICIPATION AND APPROVED TEACHING PROGRAM STATUS NO 25.02 IN EFFECT DURING THE FIRST MONTH OF THE COST REPORTING PERIOD? IF YES, COMPLETE WORKSHEET E-3, PART IV. IF NO, COMPLETE WORKSHEET D-2, PART II. 25.03 AS A TEACHING HOSPITAL, DID YOU ELECT COST REIMBURSEMENT FOR PHYSICIANS' SERVICES AS NO 25.03 DEFINED IN CMS PUB. 15-I, SECTION 2148? IF YES, COMPLETE WORKSHEET D-9. 25.04 ARE YOU CLAIMING COSTS ON LINE 70 OF WORKSHEET A? IF YES, COMPLETE WORKSHEET D-2 NO 25.04 25.05 HAS YOUR FACILITY DIRECT GME FTE CAP (COLUMN 1) OR IME CAP (COLUMN 2) BEEN REDUCED UNDER 25.05 42 CFR 413.79(c)(3) OR 42 CFR 412.105(f)(1)(iv)(B)? ENTER 'Y' FOR YES AND 'N' FOR NO IN THE APPLICABLE COLUMNS. (SEE INSTRUCTIONS) 25.06 HAS YOUR FACILITY RECEIVED ADDITIONAL DIRECT GME FTE RESIDENT CAP SLOTS OR IME FTE 25.06 RESIDENT CAP SLOTS UNDER 42 CFR 413.79(c)(4) OR 42 CFR 412.105(f)(1)(iv)(C)? ENTER 'Y' FOR YES AND 'N' FOR NO IN THE APPLICABLE COLUMNS. (SEE INSTRUCTIONS) PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/29/2009 10:18 HOSPITAL AND HEALTH CARE COMPLEX IDENTIFICATION DATA WORKSHEET S-2 (CONTINUED) OTHER INFORMATION 26 IF THIS A SOLE COMMUNITY HOSPITAL (SCH), ENTER THE NUMBER OF PERIODS SCH STATUS IN EFFECT. 26 ENTER BEGINNING AND ENDING DATES OF SCH STATUS ON LINE 26.01. SUBSCRIPT LINE 26.01 FOR NUMBER OF PERIODS IN EXCESS OF ONE AND ENTER SUBSEQUENT DATES. 26.01 ENTER THE APPLICABLE SCH DATES: BEGINNING: ENDING: 26.01 26.03 IF THIS A SOLE COMMUNITY HOSPITAL (SCH) FOR ANY PART OF THE COST REPORTING PERIOD, ENTER 26.03 THE NUMBER OF PERIODS WITHIN THIS COST REPORTING PERIOD THAT SCH STATUS WAS IN EFFECT AND THE SCH WAS EITHER PHYSICALLY LOCATED OR CLASSIFIED IN A RURAL AREA. 26.04 IF LINE 26.03 COLUMN 1 IS GREATER THAN ONE ENTER THE EFFECTIVE DATES (SEE INSTRUCTIONS): 26.04 BEGINNING: ENDING: BEGINNING: ENDING: 27 DOES THIS HOSPITAL HAVE AN AGREEMENT UNDER EITHER SECTION 1883 OR SECTION 1913 NO 27 FOR SWING BEDS? IF YES, ENTER THE AGREEMENT DATE (mm/dd/yyyy) IN COLUMN 2. 28 IF THIS FACILITY CONTAINS A HOSPITAL-BASED SNF, ARE ALL PATIENTS UNDER MANAGED CARE 28 OR THERE WAS NO MEDICARE UTILIZATION ENTER 'Y', IF 'N' COMPLETE LINES 28.01 AND 28.02. 28.01 IF HOSPITAL BASED SNF ENTER APPROPRIATE TRANSITION PERIOD 1, 2, 3, OR 100 IN COL 1, ENTER 28.01 IN COLS 2 AND 3 THE WAGE INDEX ADJUSTMENT FACTOR BEFORE AND ON OR AFTER OCTOBER 1st 28.02 ENTER IN COL 1 THE HOSPITAL BASED SNF FACILITY SPECIFIC RATE (FROM YOUR F.I.) 28.02 If YOU HAVE NOT TRANSITIONED TO 100% PPS SNF PAYMENT. IN COL 2 ENTER THE FACILITY CLASSIFICATION URBAN(1) OR RURAL(2). IN COL 3, ENTER THE SNF MSA CODE OR TWO CHARACTER CODE IF A RURAL BASED FACILITY. IN COL 4, ENTER THE SNF CBSA CODE OR TWO CHARACTER CODE IF RURAL BASED FACILITY. A NOTICE PUBLISHED IN THE 'FEDERAL REGISTER' VOL. 68, NO. 149 AUGUST 4, 2003 PROVIDED FOR AN INCREASE IN THE RUG PAYMENTS BEGINNING 10/01/2003. CONGRESS EXPECTED THIS INCREASE TO BE USED FOR DIRECT PATIENT CARE AND RELATED EXPENSES. ENTER IN COLUMN 1 THE PERCENTAGE OF TOTAL EXPENSES FOR EACH CATEGORY TO TOTAL SNF REVENUE FROM WORKSHEET G-2, PART I, LINE 6, COLUMN 3. INDICATE IN COLUMN 2 'Y' FOR YES OR 'N' FOR NO IF THE SPENDING REFLECTS INCREASES ASSOCIATED WITH DIRECT PATIENT CARE AND RELATED EXPENSES FOR EACH CATEGORY. (SEE INSTRUCTIONS) 28.03 STAFFING 0.00 N 28.03 28.04 RECRUITMENT 0.00 N 28.04 28.05 RETENTION OF EMPLOYEES 0.00 N 28.05 28.06 TRAINING 0.00 N 28.06 28.07 OTHER (SPECIFY) 28.07 29 IS THIS A RURAL HOSPITAL WITH A CERTIFIED SNF WHICH HAS FEWER THAN 50 BEDS IN THE NO 29 AGGREGATE FOR BOTH COMPONENTS, USING THE SWING BED OPTIONAL METHOD OF REIMBURSEMENT? 30 DOES THIS HOSPITAL QUALIFY AS A RURAL PRIMARY CARE HOSPITAL (RPCH)/CRITICAL ACCESS NO 30 HOSPITAL (CAH)? SEE 42 CFR 485.606ff. 30.01 IF SO, IS THIS THE INITIAL 12 MONTH PERIOD FOR THE FACILITY OPERATED AS A RPCH/CAH? 30.01 SEE 42 CFR 413.70. 30.02 IF THIS FACILITY QUALIFIES AS AN RPCH/CAH, HAS IT ELECTED THE ALL-INCLUSIVE METHOD OF 30.02 PAYMENT FOR OUTPATIENT SERVICES? 30.03 IF THIS FACILITY QUALIFIES AS A CAH, IS IT ELIGIBLE FOR COST REIMBURSEMENT FOR AMBULANCE 30.03 SERVICES? IF YES, ENTER IN COLUMN 2 THE DATE OF ELIGIBILITY DETERMINATION (DATE MUST BE ON OR AFTER 12/21/2000) 30.04 IF THIS FACILITY QUALIFIES AS A CAH, IS IT ELIGIBLE FOR COST REIMBURSEMENT FOR I&R TRAINING 30.04 PROGRAMS? ENTER 'Y' FOR YES AND 'N' FOR NO. IF YES, THE GME ELIMINATION WOULD NOT BE ON WORKSHEET B, PART I, COLUMN 26 AND THE PROGRAM WOULD BE COST REIMBURSED. IF YES COMPLETE WORKSHEET D-2, PART II. 31 IS THIS A RURAL HOSPITAL QUALIFYING FOR AN EXCEPTION TO THE CRNA FEE SCHEDULE? NO 31 SEE 42 CFR 412.113(c). MISCELLANEOUS COST REPORTING INFORMATION 32 IS THIS AN ALL-INCLUSIVE RATE PROVIDER? IF YES, ENTER THE METHOD USED (A, B, OR E ONLY) NO 32 IN COLUMN 2. 33 IS THIS A NEW HOSPITAL UNDER 42 CFR 412.300 PPS CAPITAL? ENTER 'Y' FOR YES AND 'N' FOR NO 33 NO IN COLUMN 1. IF YES, FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2002, DO YOU ELECT TO BE REIMBURSED AT 100% FEDERAL CAPITAL PAYMENT. ENTER 'Y' FOR YES AND 'N' FOR NO IN COLUMN 2. 34 IS THIS A NEW HOSPITAL UNDER 42 CFR 413.40(f)(1)(i) TEFRA? NO 34 35 HAVE YOU ESTABLISHED A NEW SUBPROVIDER I (EXLUDED UNIT) UNDER 42 CFR 413.40(f)(1)(i)? NO 35 V XVIII XIX PROSPECTIVE PAYMENT SYSTEM (PPS) - CAPITAL 1 2 3 36 DO YOU ELECT FULLY PROSPECTIVE PAYMENT METHODOLOGY FOR CAPITAL COSTS? NO YES NO 36 36.01 DOES YOUR FACILITY QUALIFY AND RECEIVE PAYMENT FOR DISPROPORTIONATE SHARE IN ACCORDANCE NO NO NO 36.01 WITH 42CFR412.320? 37 DO YOU ELECT HOLD HARMLESS PAYMENT METHODOLOGY FOR CAPITAL COSTS? NO NO NO 37 37.01 IF YOU ARE A HOLD HARMLESS PROVIDER, ARE YOU FILING ON THE BASIS OF 100% OF FEDERAL RATE? NO NO NO 37.01 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/29/2009 10:18 HOSPITAL AND HEALTH CARE COMPLEX IDENTIFICATION DATA WORKSHEET S-2 (CONTINUED) TITLE XIX INPATIENT HOSPITAL SERVICES 38 DO YOU HAVE TITLE XIX INPATIENT HOSPITAL SERVICES? YES 38 38.01 IS THIS HOSPITAL REIMBURSED FOR TITLE XIX THROUGH THE COST REPORT EITHER IN FULL OR IN PART? NO 38.01 38.02 DOES THE TITLE XIX PROGRAM REDUCE CAPITAL FOLLOWING THE MEDICARE METHODOLOGY? NO 38.02 38.03 ARE TITLE XIX NF PATIENTS OCCUPYING TITLE XVIII SNF BEDS (DUAL CERTIFICATION)? NO 38.03 38.04 DO YOU OPERATE AN ICF/MR FACILITY FOR PURPOSES OF TITLE XIX? NO 38.04 40 ARE THERE ANY RELATED ORGANIZATION OR HOME OFFICE COSTS AS DEFINED IN CMS PUB. 15-I, YES 15H032 40 CHAPTER 10? IF YES, AND THERE ARE HOME OFFICE COSTS, ENTER IN COLUMN 2 THE HOME OFFICE PROVIDER NUMBER. (SEE INSTRUCTIONS) IF THIS FACILITY IS PART OF A CHAIN ORGANIZATION, ENTER THE NAME AND ADDRESS OF THE HOME OFFICE. 40.01 NAME: FI/CONTRACTOR'S NAME: FI/CONTRACTOR'S NUMBER: 40.01 40.02 STREET: P.O.BOX: 40.02 40.03 CITY: STATE: ZIP CODE: 40.03 41 ARE PROVIDER BASED PHYSICIANS' COSTS INCLUDED IN WORKSHEET A? YES 41 42 ARE PHYSICAL THERAPY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? YES 42 42.01 ARE OCCUPATIONAL THERAPY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? YES 42.01 42.02 ARE SPEECH PATHOLOGY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? YES 42.02 43 ARE RESPIRATORY THERAPY SERVICES PROVIDED BY OUTSIDE PROVIDERS? NO 43 44 IF YOU ARE CLAIMING COST FOR RENAL SERVICES ON WORKSHEET A, ARE THEY INPAT SERVICES ONLY? NO 44 45 HAVE YOU CHANGED YOUR COST ALLOCATION METHODOLOGY FROM THE PREVIOUSLY FILE COST REPORT? NO 45 SEE CMS PUB. 15-II, SECTION 3617. IF YES, ENTER THE APPROVAL DATE (mm/dd/yyyy) IN COLUMN 2. 45.01 WAS THERE A CHANGE IN THE STATISTICAL BASIS? 45.01 45.02 WAS THERE A CHANGE IN THE ORDER OF ALLOCATION? 45.02 45.03 WAS THERE A CHANGE TO THE SIMPLIFIED COST FINDING METHOD? 45.03 46 IF YOU ARE PARTICIPATING IN THE NHCMQ DEMONSTRATION PROJECT (MUST HAVE A HOSPITAL-BASED SNF) 46 DURING THIS COST REPORTING PERIOD, ENTER THE PHASE. IF THIS FACILITY CONTAINS A PROVIDER THAT QUALIFIES FOR AN EXEMPTION FROM THE APPLICATION OF THE LOWER OF COST OR CHARGES, ENTER A 'Y' FOR EACH COMPONENT AND TYPE OF SERVICE THAT QUALIFIES FOR THE EXEMPTION; ENTER 'N' IF NOT EXEMPT (SEE 42 CFR 413.13). OUTPATIENT OUTPATIENT OUTPATIENT PART A PART B ASC RADIOLOGY DIAGNOSTIC 1 2 3 4 5 47 HOSPITAL N N N N N 47 48 SUBPROVIDER I N N N N N 48 49 SKILLED NURSING FACILITY N N 49 50 HOME HEALTH AGENCY N N 50 52 DOES THIS HOSPITAL CLAIM EXPENDITURES FOR EXTRAORDINARY CIRCUMSTANCES IN ACCORDANCE WITH NO 52 42 CFR 412.348(e)? 52.01 IF YOU ARE A FULLY PROSPECTIVE OR HOLD HARMLESS PROVIDER ARE YOU ELIGIBLE FOR THE SPECIAL NO 52.01 EXCEPTION PAYMENT PURSUANT TO 42 CFR 412.348(g)? IF YES, COMPLETE L, PART IV. 53 IF THIS IS A MEDICARE DEPENDENT HOSPITAL (MDH), ENTER THE NUMBER OF PERIODS MDH STATUS IN 53 EFFECT. ENTER BEGINNING AND ENDING DATES OF MDH STATUS ON LINE 53.01. SUBSCRIPT LINE 53.01 FOR NUMBER OF PERIODS IN EXCESS OF ONE AND ENTER SUBSEQUENT DATES. 53.01 MDH PERIOD: BEGINNING: ENDING: 53.01 54 LIST AMOUNTS OF MALPRACTICE PREMIUMS AND PAID LOSSES: 54 PREMIUMS: PAID LOSSES: AND/OR SELF INSURANCE: 121593 54.01 ARE MALPRACTICE PREMIUMS AND PAID LOSSES REPORTED IN OTHER THAN THE ADMINISTRATIVE AND NO 54.01 GENERAL COST CENTER? IF YES, SUBMIT SUPPORTING SCHEDULE LISTING COST CENTERS AND AMOUNTS CONTAINED THEREIN. 55 DOES YOUR FACILITY QUALIFY FOR ADDITIONAL PROSPECTIVE PAYMENT IN ACCORDANCE WITH NO 55 42 CFR 412.107. ENTER 'Y' FOR YES AND 'N' FOR NO. DATE Y/N LIMIT Y/N FEES 0 1 2 3 4 56 ARE YOU CLAIMING AMBULANCE COSTS? IF YES, ENTER IN COL 2 THE PAYMENT LIMIT / / NO 0.00 NO 56 PROVIDED FROM YOUR FISCAL INTERMEDIARY. IF THIS IS FIRST YEAR OF OPERATIONS, NO ENTRY IS REQUIRED IN COL 2. IF COL 1 IS 'Y', ENTER 'Y' OR 'N' IN COL 3 WHETHER THIS IS YOUR FIRST YEAR OF OPERATIONS FOR RENDERING AMBULANCE SERVICES. ENTER IN COL 4, IF APPLICABLE, THE FEE SCHEDULES AMOUNTS FOR THE PERIOD BEGINNING ON OR AFTER 4/1/2002. 57 ARE YOU CLAIMING NURSING AND ALLIED HEALTH COSTS? NO 57 58 ARE YOU AN INPATIENT REHABILITATION FACILITY (IRF), OR DO YOU CONTAIN AN IRF SUBPROVIDER? NO 58 ENTER IN COLUMN 1 'Y' FOR YES AND 'N' FOR NO. IF YES HAVE YOU MADE THE ELECTION FOR 100% PPS REIMBURSEMENT? ENTER IN COLUMN 2 'Y' FOR YES AND 'N' FOR NO. THIS OPTION IS ONLY AVAILABLE FOR COST REPORTING PERIODS BEGINNING ON OR AFTER 1/1/2002 AND BEFORE 10/1/2002. 58.01 IF LINE 58 COLUMN 1 IS Y, DOES THE FACILITY HAVE A TEACHING PROGRAM IN THE MOST RECENT 58.01 COST REPORTING PERIOD ENDING ON OR BEFORE NOVEMBER 15, 2004? ENTER IN COLUMN 1 'Y' FOR YES OR 'N' FOR NO. IS THE FACILITY TRAINING RESIDENTS IN A NEW TEACHING PROGRAM IN ACCORDANCE WITH FR VOL 70, NO 156 DATED AUGUST 15, 2005 PAGE 47929? ENTER IN COLUMN 2 'Y' FOR YES OR 'N' FOR NO. IF COLUMN 2 IS Y, ENTER 1, 2, OR 3 RESPECTIVELY IN COLUMN 3 (SEE INSTRUCTIONS) IF THE CURRENT COST REPORTING PERIOD COVERS THE BEGINNING OF THE FOURTH ENTER 4 IN COLUMN 3, OR IF THE SUBSEQUENT ACADEMIC YEARS OF THE NEW TEACHING PROGRAM IN EXISTENCE, ENTER 5. (SEE INSTRUCTIONS) 59 ARE YOU A LONG TERM CARE HOSPITAL (LTCH), OR DO YOU CONTAIN A LTCH SUBPROVIDER? NO 59 ENTER IN COLUMN 1 'Y' FOR YES AND 'N' FOR NO. IF YES HAVE YOU MADE THE ELECTION FOR 100% PPS REIMBURSEMENT? ENTER IN COLUMN 2 'Y' FOR YES AND 'N' FOR NO. (SEE INSTRUCTIONS) PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/29/2009 10:18 HOSPITAL AND HEALTH CARE COMPLEX IDENTIFICATION DATA WORKSHEET S-2 (CONTINUED) 60 ARE YOU AN INPATIENT PSYCHIATRIC FACILITY (IPF), OR DO YOU CONTAIN AN IPF SUBPROVIDER? NO 60 ENTER IN COLUMN 1 'Y' FOR YES AND 'N' FOR NO. IF YES, IS THE IPF OR IPF SUBPROVIDER A NEW FACILITY? ENTER IN COLUMN 2 'Y' FOR YES AND 'N' FOR NO. (SEE INSTRUCTIONS) 60.01 IF LINE 60 COLUMN 1 IS Y, DOES THE FACILITY HAVE A TEACHING PROGRAM IN THE MOST RECENT 60.01 COST REPORTING PERIOD ENDING ON OR BEFORE NOVEMBER 15, 2004? ENTER 'Y' FOR YES OR 'N' FOR NO. IS THE FACILITY TRAINING RESIDENTS IN A NEW TEACHING PROGRAM IN ACCORDANCE WITH 42 CFR SEC. 412.424(d)(1)(iii)(2)? ENTER IN COLUMN 2 'Y' FOR YES OR 'N' FOR NO. IF COLUMN 2 IS Y, ENTER 1, 2, OR 3 RESPECTIVELY IN COLUMN 3 (SEE INSTRUCTIONS). IF THE CURRENT COST REPORTING PERIOD COVERS THE BEGINNING OF THE FOURTH ENTER 4 IN COLUMN 3, OR IF THE SUBSEQUENT ACADEMIC YEARS OF THE NEW TEACHING PROGRAM IN EXISTENCE, ENTER 5 (SEE INSTR.) MULTICAMPUS 61 DOES THE HOSPITAL HAVE A MULTICAMPUS? ENTER 'Y' FOR YES AND 'N' FOR NO. NO 61 IF LINE 61 IS YES, ENTER THE NAME IN COL. 0, COUNTY IN COL. 1, STATE IN COL. 2, ZIP IN COL. 3, CBSA IN COL. 4 AND FTE/CAMPUS IN COL. 5. FTE/ COUNTY: STATE: ZIP CODE CBSA CAMPUS 1 2 3 4 5 SETTLEMENT DATA 63 WAS THE COST REPORT FILED USING THE PS&R (EITHER IN ITS ENTIRETY OR FOR TOTAL CHARGES NO 63 AND DAYS ONLY)? ENTER 'Y' FOR YES AND 'N' FOR NO IN COLUMN 1. IF COLUMN 1 IS 'Y', ENTER THE 'PAID THROUGH' DATE OF THE PS&R IN COLUMN 2 (mm/dd/yyyy) PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:18 HOSPITAL AND HEALTH CARE COMPLEX STATISTICAL DATA WORKSHEET S-3 PART I ------------I/P DAYS / O/P VISITS / TRIPS----------- CAH LTCH OBS. NO. OF BED DAYS PATIENT TITLE TITLE NONCOVERED TITLE BEDS COMPONENT BEDS AVAILABLE HOURS V XVIII DAYS XIX ADMITTED 1 2 2.01 3 4 4.01 5 5.01 1 HOSPITAL ADULTS & PEDS, EXCL 31 11315 2714 465 1 SWING BED, OBSERV & HOSPICE DAYS 2 HMO 736 903 2 3 HOSPITAL ADULTS & PEDS - 3 SWING BED SNF 4 HOSPITAL ADULTS & PEDS - 4 SWING BED NF 5 TOTAL ADULTS & PEDS 31 11315 2714 465 5 EXCL OBSERVATION BEDS 6 INTENSIVE CARE UNIT 6 7 CORONARY CARE UNIT 7 8 BURN INTENSIVE CARE UNIT 8 9 SURGICAL INTENSIVE CARE UNIT 9 10 OTHER SPECIAL CARE (SPECIFY) 10 11 NURSERY 11 12 TOTAL HOSPITAL 31 11315 2714 465 12 13 RPCH VISITS 13 14 SUBPROVIDER I 14 15 SKILLED NURSING FACILITY 15 16 NURSING FACILITY 16 17 OTHER LONG TERM CARE 17 18 HOME HEALTH AGENCY 18 20 ASC (DISTINCT PART) 20 21 HOSPICE (DISTINCT PART) 21 23 O/P REHAB PROVIDER 23 24 RHC I 24 25 TOTAL 31 25 26 OBSERVATION BED DAYS 75 21 26 27 AMBULANCE TRIPS 1412 27 28 EMPLOYEE DISCOUNT DAYS 28 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:18 HOSPITAL AND HEALTH CARE COMPLEX STATISTICAL DATA WORKSHEET S-3 PART I (CONTINUED) -----I/P DAYS / O/P VISITS / TRIPS---- ---INTERNS & RES FTES---- --FULL TIME EQUIV-- OBS. OBS. OBS. LESS I&R BEDS NOT TOTAL ALL BEDS BEDS NOT REPL NON- EMPLOYEES NONPAID COMPONENT ADMITTED PATIENTS ADMITTED ADMITTED TOTAL PHYS ANES NET ON PAYROLL WORKERS 5.02 6 6.01 6.02 7 8 9 10 11 1 HOSPITAL ADULTS & PEDS, EXCL. 5852 1 SWING BED, OBSERV & HOSPICE DAYS 2 HMO XIX 2 3 HOSPITAL ADULTS & PEDS - 3 SWING BED SNF 4 HOSPITAL ADULTS & PEDS - 4 SWING BED NF 5 TOTAL ADULTS & PEDS 5852 5 EXCL OBSERVATION BEDS 6 INTENSIVE CARE UNIT 6 7 CORONARY CARE UNIT 7 8 BURN INTENSIVE CARE UNIT 8 9 SURGICAL INTENSIVE CARE UNIT 9 10 OTHER SPECIAL CARE (SPECIFY) 10 11 NURSERY 641 11 12 TOTAL HOSPITAL 6493 255.00 12 13 RPCH VISITS 13 14 SUBPROVIDER I 14 15 SKILLED NURSING FACILITY 15 16 NURSING FACILITY 16 17 OTHER LONG TERM CARE 17 18 HOME HEALTH AGENCY 18 20 ASC (DISTINCT PART) 20 21 HOSPICE (DISTINCT PART) 21 23 O/P REHAB PROVIDER 23 24 RHC I 24 25 TOTAL 255.00 25 26 OBSERVATION BED DAYS 54 1947 163 1784 26 27 AMBULANCE TRIPS 27 28 EMPLOYEE DISCOUNT DAYS 101 28 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:18 HOSPITAL AND HEALTH CARE COMPLEX STATISTICAL DATA WORKSHEET S-3 PART I (CONTINUED) --------------DISCHARGES------------- TITLE TITLE TITLE TOTAL ALL COMPONENT V XVIII XIX PATIENTS 12 13 14 15 1 HOSPITAL ADULTS & PEDS, EXCL. 728 111 1760 1 SWING BED, OBSERV & HOSPICE DAYS 2 HMO XIX 2 3 HOSPITAL ADULTS & PEDS - 3 SWING BED SNF 4 HOSPITAL ADULTS & PEDS - 4 SWING BED NF 5 TOTAL ADULTS & PEDS 5 EXCL OBSERVATION BEDS 6 INTENSIVE CARE UNIT 6 7 CORONARY CARE UNIT 7 8 BURN INTENSIVE CARE UNIT 8 9 SURGICAL INTENSIVE CARE UNIT 9 10 OTHER SPECIAL CARE (SPECIFY) 10 11 NURSERY 11 12 TOTAL HOSPITAL 728 111 1760 12 13 RPCH VISITS 13 14 SUBPROVIDER I 14 15 SKILLED NURSING FACILITY 15 16 NURSING FACILITY 16 17 OTHER LONG TERM CARE 17 18 HOME HEALTH AGENCY 18 20 ASC (DISTINCT PART) 20 21 HOSPICE (DISTINCT PART) 21 23 O/P REHAB PROVIDER 23 24 RHC I 24 25 TOTAL 25 26 OBSERVATION BED DAYS 26 27 AMBULANCE TRIPS 27 28 EMPLOYEE DISCOUNT DAYS 28 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:18 HOSPITAL WAGE INDEX INFORMATION RECLASS. ADJUSTED PAID HOURS AVERAGE WORKSHEET S-3 OF SALARIES SALARIES RELATED HOURLY WAGE PART II PART II - WAGE DATA AMOUNT FROM WKST. (COL.1 + TO SALARY (COL.3 / DATA REPORTED A-6 COL.2) IN COL.3 COL.4) SOURCE SALARIES 1 2 3 4 5 6 1 TOTAL SALARIES 14056142 -131159 13924983 517190.00 26.92 1 2 NON-PHYSICIAN ANESTHETIST PART A 2 3 NON-PHYSICIAN ANESTHETIST PART B 3 4 PHYSICIAN - PART A 53352 53352 398.00 134.05 A-8-2 WORKPAPER 4 4.01 TEACHING PHYSICIAN SALARIES 4.01 5 PHYSICIAN - PART B 5 5.01 NON-PHYSICIAN - PART B 5.01 6 INTERNS & RESIDENTS (IN APPR PGM) 6 6.01 CONTRACT SERVICES, I&R 6.01 7 HOME OFFICE PERSONNEL 2560957 2560957 80707.00 31.73 A-8-1 WORKPAPER 7 8 SNF 8 8.01 EXCLUDED AREA SALARIES 1676826 -120704 1556122 78144.00 19.91 HOURS SUMMARY 8.01 OTHER WAGES & RELATED COSTS 9 CONTRACT LABOR WORKPAPERS 9 9.01 PHARMACY SERVICES UNDER CONTRACT 9.01 9.02 LABORATORY SERVICES UNDER CONTRACT 9.02 9.03 MANAGEMENT AND ADMINISTRATIVE SERVICES' 9.03 10 CONTRACT LABOR: PHYSICIAN PART A A-8-2 WORKPAPER 10 10.01 TEACHING PHYSICIAN UNDER CONTRACT 10.01 11 HOME OFFICE SALARIES & WAGE REL COSTS 2560957 2560957 80707.00 31.73 A-8-1 WORKPAPER 11 12 HOME OFFICE: PHYSICIAN PART A 12 12.01 TEACHING PHYSICIAN SALARIES 12.01 WAGE-RELATED COSTS 13 WAGE RELATED COSTS (CORE) 3767664 3767664 CMS 339 13 14 WAGE RELATED COSTS (OTHER) CMS 339 14 15 EXCLUDED AREAS 469032 469032 CMS 339 15 16 NON-PHYSICIAN ANESTHETIST PART A CMS 339 16 17 NON-PHYSICIAN ANESTHETIST PART B CMS 339 17 18 PHYSICIAN PART A CMS 339 18 18.01 PART A TEACHING PHYSICIANS CMS 339 18.01 19 PHYSICIAN PART B CMS 339 19 19.01 WAGE RELATED COSTS (RHC/FQHC) 19.01 20 INTERNS & RESIDENTS (IN APPR PGM) CMS 339 20 OVERHEAD COSTS - DIRECT SALARIES 21 EMPLOYEE BENEFITS 1138876 -1138876 21 22 ADMINISTRATIVE & GENERAL 3245972 -123319 3122653 78135.00 39.96 22 22.01 ADMINISTRATIVE & GENERAL UNDER CONTACT 22.01 23 MAINTENANCE & REPAIRS 23 24 OPERATION OF PLANT 416602 40852 457454 21259.00 21.52 24 25 LAUNDRY & LINEN SERVICE 25 26 HOUSEKEEPING 280422 27663 308085 24008.00 12.83 26 26.01 HOUSEKEEPING UNDER CONTRACT 26.01 27 DIETARY 352687 -132239 220448 15390.00 14.32 27 27.01 DIETARY UNDER CONTRACT 27.01 28 CAFETERIA 163380 163380 11406.00 14.32 28 29 MAINTENANCE OF PERSONNEL 29 30 NURSING ADMINISTRATION 290281 28465 318746 7882.00 40.44 30 31 CENTRAL SERVICES AND SUPPLY 308 75162 75470 3125.00 24.15 31 32 PHARMACY 401730 39394 441124 10906.00 40.45 32 33 MEDICAL RECORDS & MEDICAL RECORDS LIBR 392193 392193 21963.00 17.86 33 34 SOCIAL SERVICE 34 35 OTHER GENERAL SERVICE 35 HOSPITAL WAGE INDEX INFORMATION WORKSHEET S-3 PART III RECLASS. ADJUSTED PAID HOURS AVERAGE OF SALARIES SALARIES RELATED HOURLY WAGE AMOUNT FROM WKST. (COL.1 + TO SALARY (COL.3 / PART III - HOSPITAL WAGE INDEX SUMMARY REPORTED A-6 COL.2) IN COL.3 COL.4) 1 2 3 4 5 1 NET SALARIES 11495185 -131159 11364026 436483.00 26.04 1 2 EXCLUDED AREA SALARIES 1676826 -120704 1556122 78144.00 19.91 2 3 SUBTOTAL SALARIES (LINE 1 MINUS LINE 2) 9818359 -10455 9807904 358339.00 27.37 3 4 SUBTOTAL OTHER WAGES & REL COSTS 2560957 2560957 80707.00 31.73 4 5 SUBTOTAL WAGE-RELATED COSTS 3767664 3767664 38.41% 5 6 TOTAL (SUM OF LINES 3 THRU 5) 16146980 -10455 16136525 439046.00 36.75 6 7 NET SALARIES 7 8 EXCLUDED AREA SALARIES 8 9 SUBTOTAL SALARIES (LINE 7 MINUS LINE 8) 9 10 SUBTOTAL OTHER WAGES & REL COSTS 10 11 SUBTOTAL WAGE-RELATED COSTS 11 12 TOTAL (SUM OF LINES 9 THRU 11) 12 13 TOTAL OVERHEAD COSTS 6126878 -627325 5499553 194074.00 28.34 13 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (4/2005) 05/29/2009 10:18 NHCMQ DEMONSTRATION STATISTICAL DATA WORKSHEET S-7 STATISTICAL DATA M3PI SERVICES SERVICES GROUP REVENUE PRIOR TO JANUARY 1 ON OR AFTER JANUARY 1 TOTAL CODE RATE DAYS RATE DAYS 1 2 3 3.01 4 4.01 5 1 RVC/RUC 1 2 RVB/RUB 2 3 RVA/RUA 3 3.01 RUX 3.01 3.02 RUL 3.02 4 RHD/RVC 4 5 RHC/RVB 5 6 RHB/RVA 6 6.01 RVX 6.01 6.02 RVL 6.02 7 RHA/RHC 7 8 RMC/RHB 8 9 RMB/RHA 9 9.01 RHX 9.01 9.02 RHL 9.02 10 RMA/RMC 10 11 RLB/RMB 11 12 RLA/RMA 12 12.01 RMX 12.01 12.02 RML 12.02 13 SE3/RLB 13 14 SE2/RLA 14 14.01 RLX 14.01 15 SE1/SE3 15 16 SSC/SE2 16 17 SSB/SE1 17 18 SSA/SSC 18 19 CD2/SSB 19 20 CD1/SSA 20 21 CC2 21 22 CC1 22 23 CB2 23 24 CB1 24 25 CA2 25 26 CA1 26 27 IB2 27 28 IB1 28 29 IA2 29 30 IA1 30 31 BB2 31 32 BB1 32 33 BA2 33 34 BA1 34 35 PE2 35 36 PE1 36 37 PD2 37 38 PD1 38 39 PC2 39 40 PC1 40 41 PB2 41 42 PB1 42 43 PA2 43 44 PA1 44 45 DEFAULT RATE 45 46 TOTAL 46 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (6/2003) 05/29/2009 10:18 HOSPITAL UNCOMPENSATED CARE DATA WORKSHEET S-10 UNCOMPENSATED CARE INFORMATION 1 DO YOU HAVE A WRITTEN CHARITY CARE POLICY? 1 2 ARE PATIENTS WRITE-OFFS IDENTIFIED AS CHARITY? IF YES ANSWER LINES 2.01 THRU 2.04 2 2.01 IS IT AT THE TIME OF ADMISSION? 2.01 2.02 IS IT AT THE TIME OF FIRST BILLING? 2.02 2.03 IS IT AFTER SOME COLLECTION EFFORT HAS BEEN MADE? 2.03 2.04 OTHER METHODS OF WRITE-OFFS (SPECIFY) 2.04 3 ARE CHARITY WRITE-OFFS MADE FOR PARTIAL BILLS? 3 4 ARE CHARITY DETERMINATION BASED UPON ADMINISTRATIVE JUDGMENT WITHOUT FINANCIAL DATA? 4 5 ARE CHARITY DETERMINATION BASED UPON INCOME DATA ONLY? 5 6 ARE CHARITY DETERMINATION BASED UPON NET WORTH DATA? 6 7 ARE CHARITY DETERMINATION BASED UPON INCOME AND NET WORTH DATA? 7 8 DOES YOUR ACCOUNTING SYSTEM SEPARATELY IDENTIFY BAD DEBT AND CHARITY CARE? IF YES ANSWER 8.01 8 8.01 DO YOU SEPARATELY ACCOUNT FOR INPATIENT AND OUTPATIENT SERVICES? 8.01 9 IS DISCERNING CHARITY FROM BAD DEBT A HIGH PRIORITY IN YOUR INSTITUTION? IF NO ANSWER 9.01 THRU 9.04 9 9.01 IS IT BECAUSE THERE IS NOT ENOUGH STAFF TO DETERMINE ELIGIBILITY? 9.01 9.02 IS IT BECAUSE THERE IS NO FINANCIAL INCENTIVE TO SEPARATE CHARITY FROM BAD DEBT? 9.02 9.03 IS IT BECAUSE THERE IS NO CLEAR DIRECTIVE POLICY ON CHARITY DETERMINATION? 9.03 9.04 IS IT BECAUSE YOUR INSTITUTION DOES NOT DEEM THE DISTINCTION IMPORTANT? 9.04 10 IF CHARITY DETERMINATIONS ARE MADE BASED UPON INCOME DATA, WHAT IS THE MAXIMUM INCOME THAT CAN BE EARNED 10 BY PATIENTS (SINGLE WITHOUT DEPENDENT) AND STILL DETERMINED TO BE A CHARITY WRITE-OFF? 11 IF CHARITY DETERMINATIONS ARE MADE BASED UPON INCOME DATA, IS THE INCOME DIRECTLY TIED TO FEDERAL POVERTY 11 LEVEL? IF YES ANSWER LINES 11 THRU 11.04 11.01 IS THE PERCENTAGE LEVEL USED LESS THAN 100% OF THE FEDERAL POVERTY LEVEL? 11.01 11.02 IS THE PERCENTAGE LEVEL USED BETWEEN 100% AND 150% OF THE FEDERAL POVERTY LEVEL? 11.02 11.03 IS THE PERCENTAGE LEVEL USED BETWEEN 150% AND 200% OF THE FEDERAL POVERTY LEVEL? 11.03 11.04 IS THE PERCENTAGE LEVEL USED GREATER THAN 200% OF THE FEDERAL POVERTY LEVEL? 11.04 12 ARE PARTIAL WRITE-OFFS GIVEN TO HIGHER INCOME PATIENTS ON A GRADUAL SCALE? 12 13 IS THERE CHARITY CONSIDERATION GIVEN TO HIGH NET WORTH PATIENTS WHO HAVE CATASTROPHIC OR OTHER 13 EXTRAORDINARY MEDICAL EXPENSES? 14 IS YOUR HOSPITAL STATE AND LOCAL GOVERNMENT OWNED? IF YES ANSWER LINE 14.01 14 14.01 DO YOU RECEIVE DIRECT FINANCIAL SUPPORT FROM THE GOVERNMENT ENTITY FOR THE PURPOSE OF PROVIDING 14.01 UNCOMPENSATED CARE? 14.02 WHAT PERCENTAGE OF THE AMOUNT ON LINE 14.01 IS FROM GOVERNMENT FUNDING? 14.02 15 DO YOU RECEIVE RESTRICTED GRANTS FOR RENDERING CARE TO CHARITY PATIENTS? 15 16 ARE OTHER NON-RESTRICTED GRANTS USED TO SUBSIDIZE CHARITY CARE? 16 17 REVENUE RELATED TO UNCOMPENSATED CARE 7703488 17 17.01 GROSS MEDICAID REVENUES 11313827 17.01 18 REVENUES FROM STATE AND LOCAL INDIGENT CARE PROGRAMS 15888 18 19 REVENUE RELATED TO SCHIP (SEE INSTRUCTIONS) 19 20 RESTRICTED GRANTS 20 21 NON-RESTRICTED GRANTS 21 22 TOTAL GROSS UNCOMPENSATED CARE REVENUES 19033203 22 23 TOTAL CHARGES FOR PATIENTS COVERED BY STATE AND LOCAL INDIGENT CARE PROGRAMS 15888 23 24 COST TO CHARGE RATIO 0.332311 24 25 TOTAL STATE AND LOCAL INDIGENT CARE PROGRAM COST 5280 25 26 TOTAL SCHIP CHARGES FROM YOUR RECORDS 26 27 TOTAL SCHIP COST 27 28 TOTAL GROSS MEDICAID CHARGES FROM YOUR RECORDS 11313827 28 29 TOTAL GROSS MEDICAID COST 3759709 29 30 OTHER UNCOMPENSATED CARE CHARGES (FROM YOUR RECORDS) 7703488 30 31 UNCOMPENSATED CARE COST 2559954 31 32 TOTAL UNCOMPENSATED CARE COST TO THE HOSPITAL 3764989 32 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES WORKSHEET A RECLASS. NET EXP RECLASSI- TRIAL ADJUST- FOR COST CENTER SALARIES OTHER TOTAL FICATIONS BALANCE MENTS ALLOCATION 1 2 3 4 5 6 7 GENERAL SERVICE COST CENTERS 1 0100 OLD CAP REL COSTS-BLDG & FIXT 1 2 0200 OLD CAP REL COSTS-MVBLE EQUIP 2 3 0300 NEW CAP REL COSTS-BLDG & FIXT 2770975 2770975 -1702350 1068625 474568 1543193 3 4 0400 NEW CAP REL COSTS-MVBLE EQUIP 1921713 1921713 572237 2493950 4 5 0500 EMPLOYEE BENEFITS 1138876 4340183 5479059 -1138876 4340183 -912837 3427346 5 6 0600 ADMINISTRATIVE & GENERAL 3245972 2983170 6229142 316819 6545961 -1450613 5095348 6 7 0700 MAINTENANCE & REPAIRS 7 8 0800 OPERATION OF PLANT 416602 698993 1115595 39282 1154877 -720 1154157 8 9 0900 LAUNDRY & LINEN SERVICE 152250 152250 152250 9 10 1000 HOUSEKEEPING 280422 207580 488002 -125246 362756 362756 10 11 1100 DIETARY 352687 117900 470587 -183562 287025 -55 286970 11 12 1200 CAFETERIA 213565 213565 -76882 136683 12 13 1300 MAINTENANCE OF PERSONNEL 13 14 1400 NURSING ADMINISTRATION 290281 5592 295873 28465 324338 324338 14 15 1500 CENTRAL SERVICES & SUPPLY 308 12350 12658 -3486 9172 76294 85466 15 16 1600 PHARMACY 401730 1156874 1558604 -1073719 484885 -215564 269321 16 17 1700 MEDICAL RECORDS & LIBRARY 684896 684896 17 18 1800 SOCIAL SERVICE 18 20 2000 NONPHYSICIAN ANESTHETISTS 20 21 2100 NURSING SCHOOL 21 22 2200 I&R SERVICES-SALARY & FRINGES A 22 23 2300 I&R SERVICES-OTHER PRGM COSTS A 23 24 2400 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 2500 ADULTS & PEDIATRICS 2246574 400895 2647469 191701 2839170 2839170 25 33 3300 NURSERY 33 ANCILLARY SERVICE COST CENTERS 37 3700 OPERATING ROOM 1061291 244199 1305490 43250 1348740 1348740 37 39 3900 DELIVERY ROOM & LABOR ROOM 39 40 4000 ANESTHESIOLOGY 677546 677546 677546 -614827 62719 40 41 4100 RADIOLOGY-DIAGNOSTIC 990460 375492 1365952 -4086 1361866 -261 1361605 41 41.01 4101 CAT SCAN 41.01 44 4400 LABORATORY 1828253 1828253 -2403 1825850 -170 1825680 44 46.30 4650 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 4700 BLOOD STORING, PROCESSING & TRA 98786 98786 98786 98786 47 49 4900 RESPIRATORY THERAPY 418588 56717 475305 39532 514837 514837 49 50 5000 PHYSICAL THERAPY 543366 37769 581135 -206054 375081 375081 50 51 5100 OCCUPATIONAL THERAPY 126416 126416 126416 51 52 5200 SPEECH PATHOLOGY 67758 67758 67758 52 53 5300 ELECTROCARDIOLOGY 75931 75931 75931 75931 53 53.01 3950 NUTRITION SUPPORT 53.01 55 5500 MEDICAL SUPPLIES CHARGED TO PAT 863315 863315 -2515 860800 -506 860294 55 56 5600 DRUGS CHARGED TO PATIENTS 1201859 1201859 -1613 1200246 56 OUTPATIENT SERVICE COST CENTERS 60 6000 CLINIC 3487 3487 3487 60 61 6100 EMERGENCY 992159 139514 1131673 -28008 1103665 165196 1268861 61 62 6200 OBSERVATION BEDS (NON-DISTINCT 62 63.50 6310 RHC 63.50 63.60 6320 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 6500 AMBULANCE SERVICES 1561393 132133 1693526 33485 1727011 -283380 1443631 65 71 7100 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 8510 PANCREAS ACQUISITION 85.01 85.02 8520 INTESTINAL ACQUISITION 85.02 88 8800 INTEREST EXPENSE 104458 104458 -152544 -48086 48086 88 95 SUBTOTALS 13940709 17328625 31269334 -243267 31026067 -1536151 29489916 95 NONREIMBURSABLE COST CENTERS 96 9600 GIFT, FLOWER, COFFEE SHOP & CAN 38233 1093 39326 3431 42757 42757 96 98 9800 PHYSICIANS' PRIVATE OFFICES 64026 4758 68784 4859 73643 73643 98 98.01 9801 ROME CITY CLINIC 98.01 98.02 9802 LIGONIER CLINIC 98.02 100 7950 OCC. HEALTH -235109 -235109 235109 100 100.01 7951 FOUNDATION 80004 80004 80004 80004 100.01 100.02 7952 PHYSICIAN OFFICES 1112027 1112027 1112027 -1196998 -84971 100.02 100.03 7953 COMM HEALTH 13174 94052 107226 -132 107094 107094 100.03 100.04 7954 VACANT SPACE 100.04 101 TOTAL 14056142 18385450 32441592 32441592 -2733149 29708443 101 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 RECLASSIFICATIONS WORKSHEET A-6 PAGE 1 EXPLANATION OF RECLASSIFICATION ENTRY CODE ------------------------------ INCREASE ------------------------------ COST CENTER LINE # SALARY OTHER 1 2 3 4 5 1 INTEREST EXPENSE A NEW CAP REL COSTS-MVBLE EQUIP 4 9163 1 2 A ADMINISTRATIVE & GENERAL 6 143381 2 3 REHAB THERAPY B OCCUPATIONAL THERAPY 51 126416 3 4 B SPEECH PATHOLOGY 52 67758 4 5 INSURANCE C NEW CAP REL COSTS-BLDG & FIXT 3 19326 5 6 C NEW CAP REL COSTS-MVBLE EQUIP 4 130024 6 7 EQUIPMENT LEASE D NEW CAP REL COSTS-MVBLE EQUIP 4 60850 7 8 D 8 9 D 9 10 D 10 11 D 11 12 D 12 13 D 13 14 D 14 15 D 15 16 D 16 17 D 17 18 D 18 19 D 19 20 D 20 21 D 21 22 DRUGS CHARGED TO PATIENTS E DRUGS CHARGED TO PATIENTS 56 1210581 22 23 E 23 24 E 24 25 E 25 26 E 26 27 E 27 28 CLINIC DIETICIAN F CLINIC 60 3487 28 29 EMPLOYEE SALARY BENEFITS G ADMINISTRATIVE & GENERAL 6 299017 29 30 G OPERATION OF PLANT 8 40852 30 31 G HOUSEKEEPING 10 27663 31 32 G DIETARY 11 34628 32 33 G NURSING ADMINISTRATION 14 28465 33 34 G CENTRAL SERVICES & SUPPLY 15 30 34 35 G PHARMACY 16 39394 35 36 SUBTOTAL 667710 1573325 36 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 RECLASSIFICATIONS WORKSHEET A-6 PAGE 1 EXPLANATION OF CODE ------------------------------ DECREASE ------------------------------ WKST A-7 RECLASSIFICATION ENTRY COST CENTER LINE # SALARY OTHER REF. 1 6 7 8 9 10 1 INTEREST EXPENSE A INTEREST EXPENSE 88 9163 11 1 2 A INTEREST EXPENSE 88 143381 2 3 REHAB THERAPY B PHYSICAL THERAPY 50 194174 3 4 B 4 5 INSURANCE C ADMINISTRATIVE & GENERAL 6 149351 12 5 6 C 12 6 7 EQUIPMENT LEASE D ADMINISTRATIVE & GENERAL 6 5493 10 7 8 D OPERATION OF PLANT 8 1570 8 9 D HOUSEKEEPING 10 660 9 10 D DIETARY 11 1138 10 11 D CENTRAL SERVICES & SUPPLY 15 3516 11 12 D ADULTS & PEDIATRICS 25 2757 12 13 D OPERATING ROOM 37 8625 13 14 D RADIOLOGY-DIAGNOSTIC 41 24242 14 15 D RESPIRATORY THERAPY 49 1046 15 16 D PHYSICAL THERAPY 50 1833 16 17 D EMERGENCY 61 2149 17 18 D AMBULANCE SERVICES 65 5703 18 19 D GIFT, FLOWER, COFFEE SHOP & C 96 318 19 20 D PHYSICIANS' PRIVATE OFFICES 98 1419 20 21 D COMM HEALTH 100.03 383 21 22 DRUGS CHARGED TO PATIENTS E PHARMACY 16 1113113 22 23 E ADULTS & PEDIATRICS 25 26068 23 24 E OPERATING ROOM 37 22930 24 25 E RADIOLOGY-DIAGNOSTIC 41 7461 25 26 E EMERGENCY 61 35031 26 27 E AMBULANCE SERVICES 65 5978 27 28 CLINIC DIETICIAN F DIETARY 11 3487 28 29 EMPLOYEE SALARY BENEFITS G EMPLOYEE BENEFITS 5 1138876 29 30 G 30 31 G 31 32 G 32 33 G 33 34 G 34 35 G 35 36 SUBTOTAL 1336537 1573328 36 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 RECLASSIFICATIONS WORKSHEET A-6 PAGE 2 EXPLANATION OF RECLASSIFICATION ENTRY CODE ------------------------------ INCREASE ------------------------------ COST CENTER LINE # SALARY OTHER 1 2 3 4 5 1 G ADULTS & PEDIATRICS 25 220526 1 2 G OPERATING ROOM 37 104070 2 3 G RADIOLOGY-DIAGNOSTIC 41 97140 3 4 G RESPIRATORY THERAPY 49 41073 4 5 G PHYSICAL THERAPY 50 53283 5 6 G EMERGENCY 61 97291 6 7 G AMBULANCE SERVICES 65 45166 7 8 G GIFT, FLOWER, COFFEE SHOP & C 96 3749 8 9 G PHYSICIANS' PRIVATE OFFICES 98 6278 9 10 G COMM HEALTH 100.03 251 10 11 CAFETERIA RECLASS H CAFETERIA 12 163380 50185 11 12 DEPRECIATION I NEW CAP REL COSTS-MVBLE EQUIP 4 1721676 12 13 SALARY RECLASS J CENTRAL SERVICES & SUPPLY 15 75132 13 14 J ADMINISTRATIVE & GENERAL 6 422336 14 15 J MEDICAL RECORDS & LIBRARY 17 392193 15 16 J AMBULANCE SERVICES 65 176148 16 17 LAUNDRY K LAUNDRY & LINEN SERVICE 9 152250 17 18 OCCUPATIONAL HEALTH L OCC. HEALTH 100 235109 18 19 L 19 20 L 20 21 L 21 22 L 22 23 L 23 24 L 24 25 GENERAL INSURANCE & VOLUME DISCOUNT M ADMINISTRATIVE & GENERAL 6 29265 25 26 26 27 27 28 28 29 29 30 30 31 31 32 32 33 33 34 34 35 35 36 TOTAL RECLASSIFICATIONS 1967242 4360294 36 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 RECLASSIFICATIONS WORKSHEET A-6 PAGE 2 EXPLANATION OF CODE ------------------------------ DECREASE ------------------------------ WKST A-7 RECLASSIFICATION ENTRY COST CENTER LINE # SALARY OTHER REF. 1 6 7 8 9 10 1 G 1 2 G 2 3 G 3 4 G 4 5 G 5 6 G 6 7 G 7 8 G 8 9 G 9 10 G 10 11 CAFETERIA RECLASS H DIETARY 11 163380 50185 11 12 DEPRECIATION I NEW CAP REL COSTS-BLDG & FIXT 3 1721676 9 12 13 SALARY RECLASS J CENTRAL SERVICES & SUPPLY 15 75132 13 14 J ADMINISTRATIVE & GENERAL 6 422336 14 15 J MEDICAL RECORDS & LIBRARY 17 392193 15 16 J AMBULANCE SERVICES 65 176148 16 17 LAUNDRY K HOUSEKEEPING 10 152249 17 18 OCCUPATIONAL HEALTH L RADIOLOGY-DIAGNOSTIC 41 69523 18 19 L LABORATORY 44 2403 19 20 L RESPIRATORY THERAPY 49 495 20 21 L PHYSICAL THERAPY 50 63330 21 22 L MEDICAL SUPPLIES CHARGED TO P 55 2515 22 23 L DRUGS CHARGED TO PATIENTS 56 8722 23 24 L EMERGENCY 61 88119 24 25 GENERAL INSURANCE & VOLUME DISCOU M OPERATING ROOM 37 29265 25 26 26 27 27 28 28 29 29 30 30 31 31 32 32 33 33 34 34 35 35 36 TOTAL RECLASSIFICATIONS 2098401 4229135 36 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 ANALYSIS OF CHANGES DURING COST REPORTING WORKSHEET A-7 PERIOD IN CAPITAL ASSET BALANCES OF HOSPITAL PARTS I & II AND HOSPITAL HEALTH CARE COMPLEX CERTIFIED TO PARTICIPATE IN HEALTH CARE PROGRAMS PART I - ANALYSIS OF CHANGES IN OLD CAPITAL ASSET BALANCES --------- ACQUISITIONS -------- DISPOSALS FULLY BEGINNING AND ENDING DEPRECIATED DESCRIPTION BALANCES PURCHASE DONATION TOTAL RETIREMENTS BALANCE ASSETS 1 2 3 4 5 6 7 1 LAND 1 2 LAND IMPROVEMENTS 2 3 BUILDINGS AND FIXTURES 3 4 BUILDING IMPROVEMENTS 4 5 FIXED EQUIPMENT 5 6 MOVABLE EQUIPMENT 6 7 SUBTOTAL 7 8 RECONCILING ITEMS 8 9 TOTAL 9 PART II - ANALYSIS OF CHANGES IN NEW CAPITAL ASSET BALANCES --------- ACQUISITIONS -------- DISPOSALS FULLY BEGINNING AND ENDING DEPRECIATED DESCRIPTION BALANCES PURCHASE DONATION TOTAL RETIREMENTS BALANCE ASSETS 1 2 3 4 5 6 7 1 LAND 1 2 LAND IMPROVEMENTS 218604 3270749 3270749 3489353 650 2 3 BUILDINGS AND FIXTURES 417399 17653069 17653069 18070468 3 4 BUILDING IMPROVEMENTS 36334 6029559 6029559 6065893 4 5 FIXED EQUIPMENT 37653 2496 2496 40149 5 6 MOVABLE EQUIPMENT 9256710 1347095 1347095 203120 10400685 2452535 6 7 SUBTOTAL 9966700 28302968 28302968 203120 38066548 2453185 7 8 RECONCILING ITEMS -191840 -302408 -302408 -494248 8 9 TOTAL 10158540 28605376 28605376 203120 38560796 2453185 9 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 PART III - RECONCILIATION OF CAPITAL COST CENTERS WORKSHEET A-7 PARTS III & IV ---------- COMPUTATION OF RATIOS ---------- ------ ALLOCATION OF OTHER CAPITAL ------- GROSS OTHER GROSS CAPITALIZED ASSETS CAPITAL- DESCRIPTION ASSETS LEASES FOR RATIO INSURANCE TAXES RELATED TOTAL RATIO COSTS 1 2 3 4 5 6 7 8 1 OLD CAP REL COSTS-BLDG & FIXT .000000 1 2 OLD CAP REL COSTS-MVBLE EQUIP .000000 2 3 NEW CAP REL COSTS-BLDG & FIXT .000000 3 4 NEW CAP REL COSTS-MVBLE EQUIP .000000 4 5 TOTAL .000000 5 ---------------------- SUMMARY OF OLD AND NEW CAPITAL ---------------------- OTHER DEPREC- CAPITAL- DESCRIPTION IATION LEASE INTEREST INSURANCE TAXES RELATED TOTAL COSTS 9 10 11 12 13 14 15 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 1523867 19326 1543193 3 4 NEW CAP REL COSTS-MVBLE EQUIP 2303076 60850 130024 2493950 4 5 TOTAL 3826943 60850 149350 4037143 5 PART IV - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 THRU 4 ---------------------- SUMMARY OF OLD AND NEW CAPITAL ---------------------- OTHER DEPREC- CAPITAL- DESCRIPTION IATION LEASE INTEREST INSURANCE TAXES RELATED TOTAL COSTS 9 10 11 12 13 14 15 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 2770975 2770975 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 TOTAL 2770975 2770975 5 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 ADJUSTMENTS TO EXPENSES WORKSHEET A-8 EXPENSE CLASSIFICATION ON WORKSHEET A TO/ FROM WHICH THE AMOUNT IS TO BE ADJUSTED WKST A-7 DESCRIPTION BASIS AMOUNT COST CENTER LINE NO. REF 1 2 3 4 5 1 INVESTMENT INCOME-OLD BLDGS & FIXTURES OLD CAP REL COSTS-BLDG & FIXT 1 1 2 INVESTMENT INCOME-OLD MOVABLE EQUIPMENT OLD CAP REL COSTS-MVBLE EQUIP 2 2 3 INVESTMENT INCOME-NEW BLDGS & FIXTURES NEW CAP REL COSTS-BLDG & FIXT 3 3 4 INVESTMENT INCOME-NEW MOVABLE EQUIPMENT B -9163 NEW CAP REL COSTS-MVBLE EQUIP 4 11 4 5 INVESTMENT INCOME-OTHER 5 6 TRADE, QUANTITY, AND TIME DISCOUNTS 6 7 REFUNDS AND REBATES OF EXPENSES 7 8 RENTAL OF PROVIDER SPACE BY SUPPLIERS 8 9 TELEPHONE SERVICES (PAY STATIONS EXCL) 9 10 TELEVISION AND RADIO SERVICE A -720 OPERATION OF PLANT 8 10 11 PARKING LOT 11 12 PROVIDER-BASED PHYSICIAN ADJUSTMENT WKST A-8-2 -15025 12 13 SALE OF SCRAP, WASTE, ETC. 13 14 RELATED ORGANIZATION TRANSACTIONS WKST A-8-1 203269 14 15 LAUNDRY AND LINEN SERVICE 15 16 CAFETERIA - EMPLOYEES AND GUESTS B -76882 CAFETERIA 12 16 17 RENTAL OF QUARTERS TO EMPLOYEES & OTHERS 17 18 SALE OF MEDICAL AND SURGICAL SUPPLIES TO OTHER THAN PATIENTS B -506 MEDICAL SUPPLIES CHARGED TO PAT 55 18 19 SALE OF DRUGS TO OTHER THAN PATIENTS 19 20 SALE OF MEDICAL RECORDS AND ABSTRACTS 20 21 NURSING SCHOOL (TUITION,FEES,BOOKS,ETC.) 21 22 VENDING MACHINES 22 23 INCOME FROM IMPOSITION OF INTEREST, FINANCE OR PENALTY CHARGES 23 24 INTEREST EXP ON MEDICARE OVERPAYMENTS & BORROWINGS TO REPAY MEDICARE OVERPAYMENT 24 25 ADJ FOR RESPIRATORY THERAPY COSTS IN WKST EXCESS OF LIMITATION - HOSPITAL A-8-4 RESPIRATORY THERAPY 49 25 26 ADJ FOR PHYSICAL THERAPY COSTS IN WKST EXCESS OF LIMITATION - HOSPITAL A-8-4 PHYSICAL THERAPY 50 26 27 ADJ FOR HHA PHYSICAL THERAPY COSTS IN WKST EXCESS OF LIMITATION A-8-3 HOME HEALTH AGENCY 71 27 28 UTIL REVIEW-PHYSICIANS' COMPENSATION UTILIZATION REVIEW-SNF 89 28 29 DEPRECIATION--OLD BUILDINGS & FIXTURES OLD CAP REL COSTS-BLDG & FIXT 1 29 30 DEPRECIATION--OLD MOVABLE EQUIPMENT OLD CAP REL COSTS-MVBLE EQUIP 2 30 31 DEPRECIATION--NEW BUILDINGS & FIXTURES A 368346 NEW CAP REL COSTS-BLDG & FIXT 3 9 31 32 DEPRECIATION--NEW MOVABLE EQUIPMENT A -272203 NEW CAP REL COSTS-MVBLE EQUIP 4 9 32 33 NON-PHYSICIAN ANESTHETIST NONPHYSICIAN ANESTHETISTS 20 33 34 PHYSICIANS' ASSISTANT 34 35 ADJ FOR OCCUPATIONAL THERAPY COSTS IN WKST EXCESS OF LIMITATION - HOSPITAL WKST A-8-4 OCCUPATIONAL THERAPY 51 35 36 ADJ FOR SPEECH PATHOLOGY COSTS IN WKST EXCESS OF LIMITATION - HOSPITAL WKST A-8-4 SPEECH PATHOLOGY 52 36 37 MISC REVENUE B -5845 ADMINISTRATIVE & GENERAL 6 37 37.03 DIETARY CONSULTATION B -55 DIETARY 11 37.03 37.04 RADIOLOGY - MISC REVENUE B -261 RADIOLOGY-DIAGNOSTIC 41 37.04 37.05 HEALTH SENSE LAB TEST FEES B -170 LABORATORY 44 37.05 37.06 NON-PATIENT EMS REVENUE B -3432 AMBULANCE SERVICES 65 37.06 37.07 MEDICAL DIRECTOR OFFSET A -93628 ADMINISTRATIVE & GENERAL 6 37.07 37.08 TELEVISION OFFSET - DEPRECIATION A -6711 NEW CAP REL COSTS-MVBLE EQUIP 4 9 37.08 37.09 PHARMACY SALES A -215564 PHARMACY 16 37.09 37.10 RELATED PARTY INTEREST EXPENSE A 48086 INTEREST EXPENSE 88 37.10 37.11 SELF INSURANCE A -956684 EMPLOYEE BENEFITS 5 37.11 37.12 COMMUNITY HEALTH & VOLUNTEER SVCS A -58862 ADMINISTRATIVE & GENERAL 6 37.12 37.13 LOBBY EXPENSE A -3871 ADMINISTRATIVE & GENERAL 6 37.13 37.14 PROFESSIONAL ANESTHESIA SVCS A -599802 ANESTHESIOLOGY 40 37.14 37.15 LIQUOR EXPENSE OFFSET A -51 ADMINISTRATIVE & GENERAL 6 37.15 37.16 OUTSOURCED TRANSCRIPTION ADD BACK A 165196 EMERGENCY 61 37.16 37.17 COMM HOSP ANCIL PHARM B -1613 DRUGS CHARGED TO PATIENTS 56 37.17 37.18 INERUNITY SUBSIDY A -1196998 PHYSICIAN OFFICES 100.02 37.18 38 38 39 39 40 40 41 41 42 42 43 43 44 44 45 45 46 46 47 47 48 48 49 49 50 TOTAL -2733149 50 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:18 STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS AND HOME OFFICE COSTS WORKSHEET A-8-1 A. COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR THE CLAIMING OF HOME OFFICE COSTS: AMOUNT OF AMOUNT (INCL NET ADJ- WKST LINE ALLOWABLE IN WKST A, USTMENTS A-7 NO. COST CENTER EXPENSE ITEMS COST COL 5) REF 1 2 3 4 5 6 7 1 15 CENTRAL SERVICES & SUPPLY HOME OFFICE ALLOCATION 76294 76294 1 2 5 EMPLOYEE BENEFITS HOME OFFICE ALLOCATION 26868 26868 2 3 6 ADMINISTRATIVE & GENERAL HOME OFFICE ALLOCATION 3616068 4904424 -1288356 3 4 5 EMPLOYEE BENEFITS HOME OFFICE ALLOCATION 729834 779952 -50118 4 4.01 17 MEDICAL RECORDS & LIBRARY HOME OFFICE ALLOCATION 684896 684896 4.01 4.02 5 EMPLOYEE BENEFITS HOME OFFICE ALLOCATION 121709 121709 4.02 4.03 65 AMBULANCE SERVICES HOME OFFICE ALLOCATION 279948 -279948 4.03 4.04 5 EMPLOYEE BENEFITS HOME OFFICE ALLOCATION 54612 -54612 4.04 4.05 3 NEW CAP REL COSTS-BLDG & FIXT HOME OFFICE ALLOCATION 106222 106222 9 4.05 4.06 4 NEW CAP REL COSTS-MVBLE EQUIP HOME OFFICE ALLOCATION 860314 860314 9 4.06 5 TOTALS 6222205 6018936 203269 5 B. INTERRELATIONSHIP OF RELATED ORGANIZATION(S) AND/OR HOME OFFICE: THE SECRETARY, BY VIRTUE OF AUTHORITY GRANTED UNDER SECTION 1814(b)(1) OF THE SOCIAL SECURITY ACT, REQUIRES THAT YOU FURNISH THE INFORMATION REQUESTED UNDER PART B OF THIS WORKSHEET. THE INFORMATION IS USED BY THE HEALTH CARE FINANCING ADMINISTRATION AND ITS INTERMEDIARIES IN DETERMINING THAT THE COSTS APPLICABLE TO SERVICES, FACILITIES, AND SUPPLIES FURNISHED BY ORGANIZATIONS RELATED TO YOU BY COMMON OWNERSHIP OR CONTROL REPRESENT REASONABLE COSTS AS DETERMINED UNDER SECTION 1861 OF THE SOCIAL SECURITY ACT. IF YOU DO NOT PROVIDE ALL OR ANY PART OF THE REQUESTED INFORMATION, THE COST REPORT IS CONSIDERED INCOMPLETE AND NOT ACCEPTABLE FOR PURPOSES OF CLAIMING REIMBURSEMENT UNDER TITLE XVIII. -------- RELATED ORGANIZATION(S) AND/OR HOME OFFICE ---------- PERCENT PERCENT SYMBOL NAME OF NAME OF TYPE OF (1) OWNERSHIP OWNERSHIP BUSINESS 1 2 3 4 5 6 1 B PARKVIEW HEALTH SYSTEM, INC. HOME OFFICE 1 2 2 3 3 4 4 5 5 (1) USE THE FOLLOWING SYMBOLS TO INDICATE THE 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 RELATIVE OF SUCH PERSON HAS FINANCIAL INTEREST IN RELATED 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: PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 PROVIDER-BASED PHYSICIAN ADJUSTMENTS WORKSHEET A-8-2 WKST TOTAL PHYSICIAN/ UNAD- PERCENT A COST CENTER/ REMUNERA- PROFES- PROVIDER JUSTED OF UNAD- LINE PHYSICIAN IDENTIFIER TION INCL SIONAL PROVIDER RCE COMPONENT RCE JUSTED NO. FRINGES COMPONENT COMPONENT AMOUNT HOURS LIMIT RCE LIMIT 1 2 3 4 5 6 7 8 9 1 40 ANESTHESIOLOGY NORTHEAST INDIANA A 53352 53352 200300 398 38327 1916 2 53 ELECTROCARDIOLOGY FW CARDIOLOGY 3 49 RESPIRATORY THERAPY FW CARDIOLOGY 4 61 EMERGENCY PROFESSIONAL EMERGE 101 TOTAL 53352 53352 398 38327 1916 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 PROVIDER-BASED PHYSICIAN ADJUSTMENTS WORKSHEET A-8-2 WKST COST OF PROVIDER PHYSICIAN PROVIDER A COST CENTER/ MEMBERSHIP COMPONENT COST OF COMPONENT ADJUSTED RCE LINE PHYSICIAN IDENTIFIER & CONTIN. SHARE OF MALPRACTICE SHARE OF RCE DIS- ADJUST- NO. EDUCATION COLUMN 12 INSURANCE COLUMN 14 LIMIT ALLOWANCE MENT 10 11 12 13 14 15 16 17 18 1 40 ANESTHESIOLOGY NORTHEAST INDIANA A 38327 15025 15025 2 53 ELECTROCARDIOLOGY FW CARDIOLOGY 3 49 RESPIRATORY THERAPY FW CARDIOLOGY 4 61 EMERGENCY PROFESSIONAL EMERGE 101 TOTAL 38327 15025 15025 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:18 COST ALLOCATION - GENERAL SERVICE COSTS WORKSHEET B PART I NET EXP NEW CAP NEW CAP EMPLOYEE ADMINIS- OPERATION LAUNDRY COST CENTER DESCRIPTION FOR COST BLDGS & MOVABLE BENEFITS SUBTOTAL TRATIVE & OF PLANT & LINEN ALLOCATION FIXTURES EQUIPMENT GENERAL SERVICE 0 3 4 5 5A 6 8 9 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 1543193 1543193 3 4 NEW CAP REL COSTS-MVBLE EQUIP 2493950 2493950 4 5 EMPLOYEE BENEFITS 3427346 3427346 5 6 ADMINISTRATIVE & GENERAL 5095348 395891 36253 768578 6296070 6296070 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 1154157 151496 54731 112593 1472977 395058 1868035 8 9 LAUNDRY & LINEN SERVICE 152250 13033 165283 44330 24448 234061 9 10 HOUSEKEEPING 362756 18851 19179 75829 476615 127830 35363 14727 10 11 DIETARY 286970 38809 12796 54259 392834 105360 72801 636 11 12 CAFETERIA 136683 25104 40213 202000 54177 47094 635 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 324338 5279 1952 78453 410022 109970 9903 14 15 CENTRAL SERVICES & SUPPLY 85466 48484 56038 18575 208563 55937 90952 6393 15 16 PHARMACY 269321 14297 11428 108573 403619 108252 26819 16 17 MEDICAL RECORDS & LIBRARY 684896 21840 96530 803266 215439 40969 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 2839170 224242 139919 607225 3810556 1021998 420657 80129 25 33 NURSERY 3278 7846 11124 2984 6149 420 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 1348740 170821 545147 286829 2351537 630692 320443 61517 37 39 DELIVERY ROOM & LABOR ROOM 21050 8015 29065 7795 39487 421 39 40 ANESTHESIOLOGY 62719 55655 118374 31748 40 41 RADIOLOGY-DIAGNOSTIC 1361605 102300 1286530 267690 3018125 809473 191906 19394 41 41.01 CAT SCAN 41.01 44 LABORATORY 1825680 30173 1855853 497747 56601 473 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA 98786 98786 26495 47 49 RESPIRATORY THERAPY 514837 25947 74207 113136 728127 195287 48674 2114 49 50 PHYSICAL THERAPY 375081 10347 23647 99061 508136 136284 19410 3069 50 51 OCCUPATIONAL THERAPY 126416 31115 157531 42250 51 52 SPEECH PATHOLOGY 67758 16677 84435 22646 52 53 ELECTROCARDIOLOGY 75931 2159 78090 20944 4050 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PAT 860294 860294 230734 55 56 DRUGS CHARGED TO PATIENTS 1200246 1200246 321911 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 3487 858 4345 1165 60 61 EMERGENCY 1268861 95494 82718 268145 1715218 460028 179138 40789 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 1443631 66716 352066 1862413 499507 888 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 29489916 1418895 2482777 3396405 29323504 6176041 1634864 231605 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & CAN 42757 12059 4515 10333 69664 18684 22621 96 98 PHYSICIANS' PRIVATE OFFICES 73643 85766 6658 17304 183371 49181 160888 2456 98 98.01 ROME CITY CLINIC 98.01 98.02 LIGONIER CLINIC 98.02 100 OCC. HEALTH 100 100.01FOUNDATION 80004 80004 21457 100.01 100.02PHYSICIAN OFFICES -84971 22379 -62592 41982 100.02 100.03COMM HEALTH 107094 4094 3304 114492 30707 7680 100.03 100.04VACANT SPACE 100.04 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 TOTAL 29708443 1543193 2493950 3427346 29708443 6296070 1868035 234061 103 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:18 COST ALLOCATION - GENERAL SERVICE COSTS WORKSHEET B PART I HOUSE- DIETARY CAFETERIA NURSING CENTRAL PHARMACY MEDICAL COST CENTER DESCRIPTION KEEPING ADMINIS- SERVICES & RECORDS + SUBTOTAL TRATION SUPPLY LIBRARY 10 11 12 14 15 16 17 25 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 654535 10 11 DIETARY 26352 597983 11 12 CAFETERIA 17047 320953 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 3585 7012 540492 14 15 CENTRAL SERVICES & SUPPLY 32923 2550 397318 15 16 PHARMACY 9708 9703 9454 567555 16 17 MEDICAL RECORDS & LIBRARY 14830 17919 1092423 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 152267 597983 83401 205487 34186 12221 116152 6535037 25 33 NURSERY 2226 5525 28428 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 115993 36213 89222 47886 10750 79193 3743446 37 39 DELIVERY ROOM & LABOR ROOM 14294 5645 96707 39 40 ANESTHESIOLOGY 6807 156929 40 41 RADIOLOGY-DIAGNOSTIC 69465 33568 22338 3498 293479 4461246 41 41.01 CAT SCAN 41.01 44 LABORATORY 20488 155022 2586184 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA 2076 127357 47 49 RESPIRATORY THERAPY 17619 13976 9925 31123 1046845 49 50 PHYSICAL THERAPY 7026 10726 2400 14450 701501 50 51 OCCUPATIONAL THERAPY 2795 6956 209532 51 52 SPEECH PATHOLOGY 1457 2562 111100 52 53 ELECTROCARDIOLOGY 1466 8 17903 122461 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PAT 208490 47505 1347023 55 56 DRUGS CHARGED TO PATIENTS 521859 100096 2144112 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 148 254 5912 60 61 EMERGENCY 64844 35650 87837 22230 16424 156208 2778366 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 64106 157946 40051 2803 51467 2679181 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 570133 597983 319224 540492 396968 567555 1092423 28881367 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & CAN 8188 1729 130 121016 96 98 PHYSICIANS' PRIVATE OFFICES 58238 149 454283 98 98.01 ROME CITY CLINIC 98.01 98.02 LIGONIER CLINIC 98.02 100 OCC. HEALTH 100 100.01FOUNDATION 101461 100.01 100.02PHYSICIAN OFFICES 15196 -5414 100.02 100.03COMM HEALTH 2780 71 155730 100.03 100.04VACANT SPACE 100.04 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 TOTAL 654535 597983 320953 540492 397318 567555 1092423 29708443 103 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:18 COST ALLOCATION - GENERAL SERVICE COSTS WORKSHEET B PART I I&R COST & COST CENTER DESCRIPTION POST STEP- TOTAL DOWN ADJS 26 27 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 10 11 DIETARY 11 12 CAFETERIA 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 14 15 CENTRAL SERVICES & SUPPLY 15 16 PHARMACY 16 17 MEDICAL RECORDS & LIBRARY 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 6535037 25 33 NURSERY 28428 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 3743446 37 39 DELIVERY ROOM & LABOR ROOM 96707 39 40 ANESTHESIOLOGY 156929 40 41 RADIOLOGY-DIAGNOSTIC 4461246 41 41.01 CAT SCAN 41.01 44 LABORATORY 2586184 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA 127357 47 49 RESPIRATORY THERAPY 1046845 49 50 PHYSICAL THERAPY 701501 50 51 OCCUPATIONAL THERAPY 209532 51 52 SPEECH PATHOLOGY 111100 52 53 ELECTROCARDIOLOGY 122461 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PAT 1347023 55 56 DRUGS CHARGED TO PATIENTS 2144112 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 5912 60 61 EMERGENCY 2778366 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 2679181 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 28881367 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & CAN 121016 96 98 PHYSICIANS' PRIVATE OFFICES 454283 98 98.01 ROME CITY CLINIC 98.01 98.02 LIGONIER CLINIC 98.02 100 OCC. HEALTH 100 100.01FOUNDATION 101461 100.01 100.02PHYSICIAN OFFICES -5414 100.02 100.03COMM HEALTH 155730 100.03 100.04VACANT SPACE 100.04 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 TOTAL 29708443 103 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 ALLOCATION OF NEW CAPITAL RELATED COSTS WORKSHEET B PART III DIR ASSGND NEW CAP NEW CAP CAP REL ADMINIS- OPERATION LAUNDRY HOUSE- COST CENTER DESCRIPTION CAP-REL BLDGS & MOVABLE COST TO TRATIVE & OF PLANT & LINEN KEEPING COSTS FIXTURES EQUIPMENT BE ALLOC GENERAL SERVICE 0 3 4 4A 6 8 9 10 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 395891 36253 432144 432144 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 151496 54731 206227 27116 233343 8 9 LAUNDRY & LINEN SERVICE 13033 13033 3043 3054 19130 9 10 HOUSEKEEPING 18851 19179 38030 8774 4417 1204 52425 10 11 DIETARY 38809 12796 51605 7232 9094 52 2111 11 12 CAFETERIA 25104 25104 3719 5883 52 1365 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 5279 1952 7231 7548 1237 287 14 15 CENTRAL SERVICES & SUPPLY 48484 56038 104522 3839 11361 523 2637 15 16 PHARMACY 14297 11428 25725 7430 3350 778 16 17 MEDICAL RECORDS & LIBRARY 21840 21840 14787 5118 1188 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 224242 139919 364161 70143 52544 6547 12195 25 33 NURSERY 3278 7846 11124 205 768 34 178 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 170821 545147 715968 43289 40028 5028 9290 37 39 DELIVERY ROOM & LABOR ROOM 21050 8015 29065 535 4933 34 1145 39 40 ANESTHESIOLOGY 55655 55655 2179 40 41 RADIOLOGY-DIAGNOSTIC 102300 1286530 1388830 55561 23972 1585 5564 41 41.01 CAT SCAN 41.01 44 LABORATORY 30173 30173 34164 7070 39 1641 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA 1819 47 49 RESPIRATORY THERAPY 25947 74207 100154 13404 6080 173 1411 49 50 PHYSICAL THERAPY 10347 23647 33994 9354 2425 251 563 50 51 OCCUPATIONAL THERAPY 2900 51 52 SPEECH PATHOLOGY 1554 52 53 ELECTROCARDIOLOGY 2159 2159 1438 506 117 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PAT 15837 55 56 DRUGS CHARGED TO PATIENTS 22095 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 80 60 61 EMERGENCY 95494 82718 178212 31575 22377 3334 5194 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 66716 66716 34285 73 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 1418895 2482777 3901672 423905 204217 18929 45664 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & CAN 12059 4515 16574 1282 2826 656 96 98 PHYSICIANS' PRIVATE OFFICES 85766 6658 92424 3376 20097 201 4665 98 98.01 ROME CITY CLINIC 98.01 98.02 LIGONIER CLINIC 98.02 100 OCC. HEALTH 100 100.01FOUNDATION 1473 100.01 100.02PHYSICIAN OFFICES 22379 22379 5244 1217 100.02 100.03COMM HEALTH 4094 4094 2108 959 223 100.03 100.04VACANT SPACE 100.04 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 TOTAL 1543193 2493950 4037143 432144 233343 19130 52425 103 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 ALLOCATION OF NEW CAPITAL RELATED COSTS WORKSHEET B PART III DIETARY CAFETERIA NURSING CENTRAL PHARMACY MEDICAL I&R COST & COST CENTER DESCRIPTION ADMINIS- SERVICES & RECORDS + SUBTOTAL POST STEP- TRATION SUPPLY LIBRARY DOWN ADJS 11 12 14 15 16 17 25 26 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 10 11 DIETARY 70094 11 12 CAFETERIA 36123 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 789 17092 14 15 CENTRAL SERVICES & SUPPLY 287 123169 15 16 PHARMACY 1092 2931 41306 16 17 MEDICAL RECORDS & LIBRARY 2017 44950 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 70094 9386 6498 10598 889 4778 607833 25 33 NURSERY 227 12536 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 4076 2821 14845 782 3257 839384 37 39 DELIVERY ROOM & LABOR ROOM 232 35944 39 40 ANESTHESIOLOGY 280 58114 40 41 RADIOLOGY-DIAGNOSTIC 3778 6925 255 12090 1498560 41 41.01 CAT SCAN 41.01 44 LABORATORY 6377 79464 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA 85 1904 47 49 RESPIRATORY THERAPY 1573 3077 1280 127152 49 50 PHYSICAL THERAPY 1207 744 594 49132 50 51 OCCUPATIONAL THERAPY 315 286 3501 51 52 SPEECH PATHOLOGY 164 105 1823 52 53 ELECTROCARDIOLOGY 3 736 4959 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PAT 64631 1954 82422 55 56 DRUGS CHARGED TO PATIENTS 37981 4117 64193 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 17 10 107 60 61 EMERGENCY 4012 2778 6891 1195 6425 261993 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 7215 4995 12416 204 2117 128021 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 70094 35928 17092 123061 41306 44950 3857042 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & CAN 195 40 21573 96 98 PHYSICIANS' PRIVATE OFFICES 46 120809 98 98.01 ROME CITY CLINIC 98.01 98.02 LIGONIER CLINIC 98.02 100 OCC. HEALTH 100 100.01FOUNDATION 1473 100.01 100.02PHYSICIAN OFFICES 28840 100.02 100.03COMM HEALTH 22 7406 100.03 100.04VACANT SPACE 100.04 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 TOTAL 70094 36123 17092 123169 41306 44950 4037143 103 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 ALLOCATION OF NEW CAPITAL RELATED COSTS WORKSHEET B PART III COST CENTER DESCRIPTION TOTAL 27 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 10 11 DIETARY 11 12 CAFETERIA 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 14 15 CENTRAL SERVICES & SUPPLY 15 16 PHARMACY 16 17 MEDICAL RECORDS & LIBRARY 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 607833 25 33 NURSERY 12536 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 839384 37 39 DELIVERY ROOM & LABOR ROOM 35944 39 40 ANESTHESIOLOGY 58114 40 41 RADIOLOGY-DIAGNOSTIC 1498560 41 41.01 CAT SCAN 41.01 44 LABORATORY 79464 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA 1904 47 49 RESPIRATORY THERAPY 127152 49 50 PHYSICAL THERAPY 49132 50 51 OCCUPATIONAL THERAPY 3501 51 52 SPEECH PATHOLOGY 1823 52 53 ELECTROCARDIOLOGY 4959 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PAT 82422 55 56 DRUGS CHARGED TO PATIENTS 64193 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 107 60 61 EMERGENCY 261993 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 128021 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 3857042 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & CAN 21573 96 98 PHYSICIANS' PRIVATE OFFICES 120809 98 98.01 ROME CITY CLINIC 98.01 98.02 LIGONIER CLINIC 98.02 100 OCC. HEALTH 100 100.01FOUNDATION 1473 100.01 100.02PHYSICIAN OFFICES 28840 100.02 100.03COMM HEALTH 7406 100.03 100.04VACANT SPACE 100.04 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 TOTAL 4037143 103 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:18 COST ALLOCATION - STATISTICAL BASIS WORKSHEET B-1 NEW CAP NEW CAP EMPLOYEE ADMINIS- OPERATION LAUNDRY COST CENTER DESCRIPTION BLDGS & MOVABLE BENEFITS RECON- TRATIVE & OF PLANT & LINEN FIXTURES EQUIPMENT CILIATION GENERAL SERVICE SQUARE DOLLAR GROSS ACCUM SQUARE POUNDS OF FEET VALUE SALARIES COST FEET LAUNDRY 3 4 5 6A 6 8 9 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 117225 3 4 NEW CAP REL COSTS-MVBLE EQUIP 1152215 4 5 EMPLOYEE BENEFITS 13924983 5 6 ADMINISTRATIVE & GENERAL 30073 16749 3122653 -6296070 23474965 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 11508 25286 457454 1472977 75644 8 9 LAUNDRY & LINEN SERVICE 990 165283 990 303809 9 10 HOUSEKEEPING 1432 8861 308085 476615 1432 19115 10 11 DIETARY 2948 5912 220448 392834 2948 825 11 12 CAFETERIA 1907 163380 202000 1907 824 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 401 902 318746 410022 401 14 15 CENTRAL SERVICES & SUPPLY 3683 25890 75470 208563 3683 8298 15 16 PHARMACY 1086 5280 441124 403619 1086 16 17 MEDICAL RECORDS & LIBRARY 1659 392193 803266 1659 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES 22 23 I&R SERVICES-OTHER PRGM COSTS 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 17034 64643 2467100 3810556 17034 104009 25 33 NURSERY 249 3625 11124 249 545 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 12976 251860 1165361 2351537 12976 79849 37 39 DELIVERY ROOM & LABOR ROOM 1599 3703 29065 1599 546 39 40 ANESTHESIOLOGY 25713 118374 40 41 RADIOLOGY-DIAGNOSTIC 7771 594381 1087600 3018125 7771 25173 41 41.01 CAT SCAN 41.01 44 LABORATORY 2292 1855853 2292 614 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 47 BLOOD STORING, PROCESSING & T 98786 47 49 RESPIRATORY THERAPY 1971 34284 459661 728127 1971 2744 49 50 PHYSICAL THERAPY 786 10925 402475 508136 786 3983 50 51 OCCUPATIONAL THERAPY 126416 157531 51 52 SPEECH PATHOLOGY 67758 84435 52 53 ELECTROCARDIOLOGY 164 78090 164 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO P 860294 55 56 DRUGS CHARGED TO PATIENTS 1200246 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 3487 4345 60 61 EMERGENCY 7254 38216 1089450 1715218 7254 52944 61 62 OBSERVATION BEDS (NON-DISTINC 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 30823 1430411 1862413 1152 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 107783 1147053 13799272 -6296070 23027434 66202 300621 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & C 916 2086 41982 69664 916 96 98 PHYSICIANS' PRIVATE OFFICES 6515 3076 70304 183371 6515 3188 98 98.01 ROME CITY CLINIC 98.01 98.02 LIGONIER CLINIC 98.02 100 OCC. HEALTH 100 100.01 FOUNDATION 80004 100.01 100.02 PHYSICIAN OFFICES 1700 62592 1700 100.02 100.03 COMM HEALTH 311 13425 114492 311 100.03 100.04 VACANT SPACE 100.04 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:18 COST ALLOCATION - STATISTICAL BASIS WORKSHEET B-1 NEW CAP NEW CAP EMPLOYEE ADMINIS- OPERATION LAUNDRY COST CENTER DESCRIPTION BLDGS & MOVABLE BENEFITS RECON- TRATIVE & OF PLANT & LINEN FIXTURES EQUIPMENT CILIATION GENERAL SERVICE SQUARE DOLLAR GROSS ACCUM SQUARE POUNDS OF FEET VALUE SALARIES COST FEET LAUNDRY 3 4 5 6A 6 8 9 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 COST TO BE ALLOC PER B PT I 1543193 2493950 3427346 6296070 1868035 234061 103 104 UNIT COST MULT-WS B PT I 2.164483 24.695085 104 104 UNIT COST MULT-WS B PT I 13.164368 .246129 .268204 .770422 104 105 COST TO BE ALLOC PER B PT II 105 106 UNIT COST MULT-WS B PT II 106 106 UNIT COST MULT-WS B PT II 106 107 COST TO BE ALLOC PER B PT III 432144 233343 19130 107 108 UNIT COST MULT-WS B PT III 3.084752 108 108 UNIT COST MULT-WS B PT III .018409 .062967 108 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:18 COST ALLOCATION - STATISTICAL BASIS WORKSHEET B-1 HOUSE- DIETARY CAFETERIA NURSING CENTRAL PHARMACY MEDICAL COST CENTER DESCRIPTION KEEPING ADMINIS- SERVICES & RECORDS + TRATION SUPPLY LIBRARY SQUARE MEALS HOURS DIRECT COSTED COSTED GROSS FEET SERVED WORKED NRSING HRS REQUIS. REQUIS. REVENUE 10 11 12 14 15 16 17 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 73222 10 11 DIETARY 2948 33562 11 12 CAFETERIA 1907 393394 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 401 8595 268884 14 15 CENTRAL SERVICES & SUPPLY 3683 3126 1645223 15 16 PHARMACY 1086 11893 39148 1210581 16 17 MEDICAL RECORDS & LIBRARY 1659 21963 86910633 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES 22 23 I&R SERVICES-OTHER PRGM COSTS 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 17034 33562 102226 102226 141558 26068 9241169 25 33 NURSERY 249 439595 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 12976 44386 44386 198288 22930 6300635 37 39 DELIVERY ROOM & LABOR ROOM 1599 449090 39 40 ANESTHESIOLOGY 541579 40 41 RADIOLOGY-DIAGNOSTIC 7771 41144 92499 7461 23346051 41 41.01 CAT SCAN 41.01 44 LABORATORY 2292 12333661 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 47 BLOOD STORING, PROCESSING & T 165154 47 49 RESPIRATORY THERAPY 1971 17130 41099 2476201 49 50 PHYSICAL THERAPY 786 13147 9939 1149625 50 51 OCCUPATIONAL THERAPY 3426 553402 51 52 SPEECH PATHOLOGY 1786 203864 52 53 ELECTROCARDIOLOGY 164 34 1424361 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO P 863315 3779512 55 56 DRUGS CHARGED TO PATIENTS 1113113 7963742 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 181 20234 60 61 EMERGENCY 7254 43697 43697 92050 35031 12428018 61 62 OBSERVATION BEDS (NON-DISTINC 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 78575 78575 165845 5978 4094740 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 63780 33562 391275 268884 1643775 1210581 86910633 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & C 916 2119 537 96 98 PHYSICIANS' PRIVATE OFFICES 6515 619 98 98.01 ROME CITY CLINIC 98.01 98.02 LIGONIER CLINIC 98.02 100 OCC. HEALTH 100 100.01 FOUNDATION 100.01 100.02 PHYSICIAN OFFICES 1700 100.02 100.03 COMM HEALTH 311 292 100.03 100.04 VACANT SPACE 100.04 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:18 COST ALLOCATION - STATISTICAL BASIS WORKSHEET B-1 HOUSE- DIETARY CAFETERIA NURSING CENTRAL PHARMACY MEDICAL COST CENTER DESCRIPTION KEEPING ADMINIS- SERVICES & RECORDS + TRATION SUPPLY LIBRARY SQUARE MEALS HOURS DIRECT COSTED COSTED GROSS FEET SERVED WORKED NRSING HRS REQUIS. REQUIS. REVENUE 10 11 12 14 15 16 17 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 COST TO BE ALLOC PER B PT I 654535 597983 320953 540492 397318 567555 1092423 103 104 UNIT COST MULT-WS B PT I 8.939048 .815856 .241498 .012569 104 104 UNIT COST MULT-WS B PT I 17.817264 2.010131 .468829 104 105 COST TO BE ALLOC PER B PT II 105 106 UNIT COST MULT-WS B PT II 106 106 UNIT COST MULT-WS B PT II 106 107 COST TO BE ALLOC PER B PT III 52425 70094 36123 17092 123169 41306 44950 107 108 UNIT COST MULT-WS B PT III .715973 .091824 .074865 .000517 108 108 UNIT COST MULT-WS B PT III 2.088493 .063566 .034121 108 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (5/1999) 05/29/2009 10:18 COMPUTATION OF RATIO OF COST TO CHARGES WORKSHEET C PART I TOTAL COST THERAPY COST CENTER DESCRIPTION (FROM WKST B, LIMIT TOTAL RCE TOTAL PART I, COL 27) ADJUSTMENT COSTS DISALLOWANCE COSTS 1 2 3 4 5 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 6535037 6535037 6535037 25 33 NURSERY 28428 28428 28428 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 3743446 3743446 3743446 37 39 DELIVERY ROOM & LABOR ROOM 96707 96707 96707 39 40 ANESTHESIOLOGY 156929 156929 15025 171954 40 41 RADIOLOGY-DIAGNOSTIC 4461246 4461246 4461246 41 41.01 CAT SCAN 41.01 44 LABORATORY 2586184 2586184 2586184 44 46.30 BLOOD CLOTTING FACTORS ADMI 46.30 47 BLOOD STORING, PROCESSING & 127357 127357 127357 47 49 RESPIRATORY THERAPY 1046845 1046845 1046845 49 50 PHYSICAL THERAPY 701501 701501 701501 50 51 OCCUPATIONAL THERAPY 209532 209532 209532 51 52 SPEECH PATHOLOGY 111100 111100 111100 52 53 ELECTROCARDIOLOGY 122461 122461 122461 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO 1347023 1347023 1347023 55 56 DRUGS CHARGED TO PATIENTS 2144112 2144112 2144112 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 5912 5912 5912 60 61 EMERGENCY 2778366 2778366 2778366 61 62 OBSERVATION BEDS (NON-DISTI 1631450 1631450 1631450 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 2679181 2679181 2679181 65 101 SUBTOTAL 30512817 30512817 15025 30527842 101 102 LESS OBSERVATION BEDS 1631450 1631450 1631450 102 103 TOTAL 28881367 28881367 15025 28896392 103 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (5/1999) 05/29/2009 10:18 COMPUTATION OF RATIO OF COST TO CHARGES WORKSHEET C PART I (CONT) -------------- CHARGES --------------- COST TEFRA PPS COST CENTER DESCRIPTION OR OTHER INPATIENT INPATIENT INPATIENT OUTPATIENT TOTAL RATIO RATIO RATIO 6 7 8 9 10 11 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 7839381 7839381 25 33 NURSERY 439595 439595 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 1384821 4915814 6300635 .594138 .594138 .594138 37 39 DELIVERY ROOM & LABOR ROOM 185442 263648 449090 .215340 .215340 .215340 39 40 ANESTHESIOLOGY 192509 349070 541579 .289762 .289762 .317505 40 41 RADIOLOGY-DIAGNOSTIC 2561908 20784143 23346051 .191092 .191092 .191092 41 41.01 CAT SCAN 41.01 44 LABORATORY 2593151 9740510 12333661 .209685 .209685 .209685 44 46.30 BLOOD CLOTTING FACTORS ADMI 46.30 47 BLOOD STORING, PROCESSING & 64466 100688 165154 .771141 .771141 .771141 47 49 RESPIRATORY THERAPY 1092594 1383607 2476201 .422763 .422763 .422763 49 50 PHYSICAL THERAPY 164109 985516 1149625 .610200 .610200 .610200 50 51 OCCUPATIONAL THERAPY 51124 502278 553402 .378625 .378625 .378625 51 52 SPEECH PATHOLOGY 32085 171779 203864 .544971 .544971 .544971 52 53 ELECTROCARDIOLOGY 422508 1001853 1424361 .085976 .085976 .085976 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO 1519620 2259892 3779512 .356401 .356401 .356401 55 56 DRUGS CHARGED TO PATIENTS 3770701 4193041 7963742 .269234 .269234 .269234 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 20234 20234 .292181 .292181 .292181 60 61 EMERGENCY 1532830 10895188 12428018 .223557 .223557 .223557 61 62 OBSERVATION BEDS (NON-DISTI 1401788 1401788 1.163835 1.163835 1.163835 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 4094740 4094740 .654298 .654298 .654298 65 101 SUBTOTAL 23846844 63063789 86910633 101 102 LESS OBSERVATION BEDS 102 103 TOTAL 23846844 63063789 86910633 103 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:18 APPORTIONMENT OF INPATIENT ROUTINE SERVICE CAPITAL COSTS WORKSHEET D PART I CHECK [ ] TITLE V APPLICABLE [XX] TITLE XVIII-PT A BOXES [ ] TITLE XIX ---------- OLD CAPITAL ---------- ---------- NEW CAPITAL ---------- REDUCED REDUCED CAPITAL SWING-BED CAPITAL CAPITAL SWING-BED CAPITAL COST CENTER DESCRIPTION RELATED ADJUSTMENT RELATED RELATED ADJUSTMENT RELATED COST COST COST COST 1 2 3 4 5 6 INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 607833 607833 25 26 INTENSIVE CARE UNIT 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 31 33 NURSERY 12536 12536 33 101 TOTAL 620369 620369 101 ---- OLD CAPITAL ---- ---- NEW CAPITAL ---- INPATIENT INPATIENT TOTAL INPATIENT PER PROGRAM PER PROGRAM COST CENTER DESCRIPTION PATIENT PROGRAM DIEM CAPITAL DIEM CAPITAL DAYS DAYS COST COST 7 8 9 10 11 12 INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 7799 2714 77.94 211529 25 26 INTENSIVE CARE UNIT 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 31 33 NURSERY 641 19.56 33 101 TOTAL 8440 2714 211529 101 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS WORKSHEET D PART II CHECK [ ] TITLE V [XX] HOSPITAL (15-0146) [ ] SUB III [XX] PPS APPLICABLE [XX] TITLE XVIII-PT A [ ] SUB I [ ] SUB IV [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II OLD NEW ---- OLD CAPITAL ---- ---- NEW CAPITAL ---- CAPITAL CAPITAL INPATIENT RATIO OF RATIO OF COST CENTER DESCRIPTION RELATED RELATED TOTAL PROGRAM COST TO CAPITAL COST TO CAPITAL COST COST CHARGES CHARGES CHARGES COSTS CHARGES COSTS 1 2 3 4 5 6 7 8 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 839384 6300635 398347 .133222 53069 37 39 DELIVERY ROOM & LABOR ROOM 35944 449090 .080037 39 40 ANESTHESIOLOGY 58114 541579 48999 .107305 5258 40 41 RADIOLOGY-DIAGNOSTIC 1498560 23346051 1536023 .064189 98596 41 41.01 CAT SCAN 41.01 44 LABORATORY 79464 12333661 1467131 .006443 9453 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 47 BLOOD STORING, PROCESSING & T 1904 165154 40400 .011529 466 47 49 RESPIRATORY THERAPY 127152 2476201 636987 .051350 32709 49 50 PHYSICAL THERAPY 49132 1149625 115949 .042737 4955 50 51 OCCUPATIONAL THERAPY 3501 553402 38611 .006326 244 51 52 SPEECH PATHOLOGY 1823 203864 22985 .008942 206 52 53 ELECTROCARDIOLOGY 4959 1424361 265165 .003482 923 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO P 82422 3779512 647551 .021808 14122 55 56 DRUGS CHARGED TO PATIENTS 64193 7963742 1642718 .008061 13242 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 107 20234 .005288 60 61 EMERGENCY 261993 12428018 849721 .021081 17913 61 62 OBSERVATION BEDS (NON-DISTINC 151743 1401788 .108250 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 3260395 74536917 7710587 251156 101 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 APPORTIONMENT OF INPATIENT ROUTINE SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART III CHECK [ ] TITLE V APPLICABLE [XX] TITLE XVIII-PT A BOXES [ ] TITLE XIX INPATIENT NONPHYSICIAN MEDICAL SWING-BED TOTAL INPATIENT PROGRAM COST CENTER DESCRIPTION ANESTHETIST EDUCATION ADJUSTMENT TOTAL PATIENT PER PROGRAM PASS THRU COST COST AMOUNT COSTS DAYS DIEM DAYS COSTS 1 2 3 4 5 6 7 8 INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 7799 2714 25 26 INTENSIVE CARE UNIT 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 31 33 NURSERY 641 33 34 SKILLED NURSING FACILITY 34 35 NURSING FACILITY 35 101 TOTAL 8440 2714 101 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:18 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV CHECK [ ] TITLE V [XX] HOSPITAL (15-0146) [ ] SUB IV [ ] PPS APPLICABLE [XX] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II [ ] NF [ ] SUB III [ ] ICF/MR OUTPATIENT NONPHYSICIAN NONPHYSICIAN MEDICAL COST CENTER DESCRIPTION ANESTHETIST ANESTHETIST EDUCATION TOTAL COST COST COST N/A N/A N/A COSTS 1 1.01 2 2.01 2.02 2.03 3 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 37 39 DELIVERY ROOM & LABOR ROOM 39 40 ANESTHESIOLOGY 40 41 RADIOLOGY-DIAGNOSTIC 41 41.01 CAT SCAN 41.01 44 LABORATORY 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 47 BLOOD STORING, PROCESSING & T 47 49 RESPIRATORY THERAPY 49 50 PHYSICAL THERAPY 50 51 OCCUPATIONAL THERAPY 51 52 SPEECH PATHOLOGY 52 53 ELECTROCARDIOLOGY 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO P 55 56 DRUGS CHARGED TO PATIENTS 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 60 61 EMERGENCY 61 62 OBSERVATION BEDS (NON-DISTINC 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 101 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:18 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV CHECK [ ] TITLE V [XX] HOSPITAL (15-0146) [ ] SUB IV [ ] PPS APPLICABLE [XX] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II [ ] NF [ ] SUB III [ ] ICF/MR INPATIENT OUTPATIENT RATIO OF OUTPATIENT INPATIENT PROGRAM OUTPATIENT COST CENTER DESCRIPTION PASS THROUGH TOTAL COST TO RATIO OF COST PROGRAM PASS THROUGH PROGRAM COSTS CHARGES CHARGES TO CHARGES CHARGES COSTS CHARGES 3.01 4 5 5.01 6 7 8 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 6300635 398347 1082114 37 39 DELIVERY ROOM & LABOR ROOM 449090 39 40 ANESTHESIOLOGY 541579 48999 53852 40 41 RADIOLOGY-DIAGNOSTIC 23346051 1536023 5419169 41 41.01 CAT SCAN 41.01 44 LABORATORY 12333661 1467131 63526 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 47 BLOOD STORING, PROCESSING & T 165154 40400 55175 47 49 RESPIRATORY THERAPY 2476201 636987 470485 49 50 PHYSICAL THERAPY 1149625 115949 50 51 OCCUPATIONAL THERAPY 553402 38611 51 52 SPEECH PATHOLOGY 203864 22985 52 53 ELECTROCARDIOLOGY 1424361 265165 370182 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO P 3779512 647551 319492 55 56 DRUGS CHARGED TO PATIENTS 7963742 1642718 1681557 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 20234 60 61 EMERGENCY 12428018 849721 2438299 61 62 OBSERVATION BEDS (NON-DISTINC 1401788 420003 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 74536917 7710587 12373854 101 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:18 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV CHECK [ ] TITLE V [XX] HOSPITAL (15-0146) [ ] SUB IV [ ] PPS APPLICABLE [XX] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II [ ] NF [ ] SUB III [ ] ICF/MR OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT PROGRAM PROGRAM PROGRAM COST CENTER DESCRIPTION PROGRAM PROGRAM PASS THROUGH PASS THROUGH PASS THROUGH CHARGES CHARGES COSTS COSTS COSTS 8.01 8.02 9 9.01 9.02 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 37 39 DELIVERY ROOM & LABOR ROOM 39 40 ANESTHESIOLOGY 40 41 RADIOLOGY-DIAGNOSTIC 41 41.01 CAT SCAN 41.01 44 LABORATORY 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 47 BLOOD STORING, PROCESSING & T 47 49 RESPIRATORY THERAPY 49 50 PHYSICAL THERAPY 50 51 OCCUPATIONAL THERAPY 51 52 SPEECH PATHOLOGY 52 53 ELECTROCARDIOLOGY 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO P 55 56 DRUGS CHARGED TO PATIENTS 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 60 61 EMERGENCY 61 62 OBSERVATION BEDS (NON-DISTINC 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 101 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/29/2009 10:18 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI CHECK [ ] TITLE V - O/P [XX] HOSPITAL (15-0146) [ ] SNF APPLICABLE [XX] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [ ] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR --------- PROGRAM CHARGES ---------- OUTPATIENT COST TO CHARGE RATIO FROM WORKSHEET C, AMBULATORY OTHER COST CENTER DESCRIPTION PART II PART I PART II SURGICAL OUTPATIENT OUTPATIENT COL. 8 COL. 9 COL. 9 CENTER RADIOLOGY DIAGNOSTIC 1 1.01 1.02 2 3 4 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM .594138 .594138 .594138 37 39 DELIVERY ROOM & LABOR ROOM .215340 .215340 .215340 39 40 ANESTHESIOLOGY .289762 .289762 .289762 40 41 RADIOLOGY-DIAGNOSTIC .191092 .191092 .191092 41 41.01 CAT SCAN 41.01 44 LABORATORY .209685 .209685 .209685 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA .771141 .771141 .771141 47 49 RESPIRATORY THERAPY .422763 .422763 .422763 49 50 PHYSICAL THERAPY .610200 .610200 .610200 50 51 OCCUPATIONAL THERAPY .378625 .378625 .378625 51 52 SPEECH PATHOLOGY .544971 .544971 .544971 52 53 ELECTROCARDIOLOGY .085976 .085976 .085976 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PAT .356401 .356401 .356401 55 56 DRUGS CHARGED TO PATIENTS .269234 .269234 .269234 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC .292181 .292181 .292181 60 61 EMERGENCY .223557 .223557 .223557 61 62 OBSERVATION BEDS (NON-DISTINCT 1.163835 1.163835 1.163835 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES .654298 .654298 .654298 65 65.01 AMBULANCE CHARGES (S-2 LINE 56. .654298 .654298 65.01 65.02 AMBULANCE CHARGES (S-2 LINE 56. .654298 .654298 65.02 65.03 AMBULANCE CHARGES (S-2 LINE 56. .654298 .654298 65.03 101 SUBTOTAL 101 102 CRNA CHARGES 102 103 LESS PBP CLINIC LAB SERV-PGM ONLY CHRGS 103 104 NET CHARGES 104 PART VI - VACCINE COST APPORTIONMENT 1 1 DRUGS CHARGED TO PATIENTS - RATIO OF COST TO CHARGES .269234 1 2 PROGRAM VACCINE CHARGES 2 2.01 PROGRAM VACCINE CHARGES 2.01 3 PROGRAM COSTS 3 3.01 PROGRAM COSTS 3.01 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/29/2009 10:18 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI CHECK [ ] TITLE V - O/P [XX] HOSPITAL (15-0146) [ ] SNF APPLICABLE [XX] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [ ] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR ------------------ PROGRAM CHARGES ------------------- --------- PROGRAM COST --------- ALL PPS SER- PPS SER- PPS SER- OUTPATIENT OTHER (1) VICES ALL OTHER VICES VICES AMBULATORY OTHER COST CENTER DESCRIPTION (SEE (SEE (SEE (SEE (SEE SURGICAL OUTPATIENT OUTPATIENT INSTRU.) INSTRU.) INSTRU.) INSTRU.) INSTRU.) CENTER RADIOLOGY DIAGNOSTIC 5 5.01 5.02 5.03 5.04 6 7 8 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 1082114 37 39 DELIVERY ROOM & LABOR ROOM 39 40 ANESTHESIOLOGY 53852 40 41 RADIOLOGY-DIAGNOSTIC 5419169 3838 41 41.01 CAT SCAN 41.01 44 LABORATORY 63526 441 44 46.30 BLOOD CLOTTING FACTORS ADMIN C 46.30 47 BLOOD STORING, PROCESSING & TR 55175 47 49 RESPIRATORY THERAPY 470485 49 50 PHYSICAL THERAPY 50 51 OCCUPATIONAL THERAPY 51 52 SPEECH PATHOLOGY 52 53 ELECTROCARDIOLOGY 370182 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PA 319492 55 56 DRUGS CHARGED TO PATIENTS 1681557 4834 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 60 61 EMERGENCY 2438299 61 62 OBSERVATION BEDS (NON-DISTINCT 420003 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 65.01 AMBULANCE CHARGES (S-2 LINE 56 65.01 65.02 AMBULANCE CHARGES (S-2 LINE 56 65.02 65.03 AMBULANCE CHARGES (S-2 LINE 56 65.03 101 SUBTOTAL 12373854 9113 101 102 CRNA CHARGES 102 103 PBP CLINIC LAB 103 104 NET CHARGES 12373854 9113 104 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/29/2009 10:18 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI CHECK [ ] TITLE V - O/P [XX] HOSPITAL (15-0146) [ ] SNF APPLICABLE [XX] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [ ] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR -------------------- PROGRAM COST -------------------- HOSPITAL HOSPITAL PPS PPS PPS I/P PART B I/P PART B SERVICES ALL OTHER SERVICES SERVICES CHARGES COST COST CENTER DESCRIPTION ALL OTHER (COLUMNS (COLUMNS (COLUMNS (COLUMNS (SEE (COLUMNS (COLS 1x5) 1.01x5.01) 1.01x5.02) 1.01x5.03 1.01x5.04 INSTRU.) 1.02x10) 9 9.01 9.02 9.03 9.04 10 11 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 642925 37 39 DELIVERY ROOM & LABOR ROOM 39 40 ANESTHESIOLOGY 15604 40 41 RADIOLOGY-DIAGNOSTIC 1035560 733 41 41.01 CAT SCAN 41.01 44 LABORATORY 13320 92 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA 42548 47 49 RESPIRATORY THERAPY 198904 49 50 PHYSICAL THERAPY 50 51 OCCUPATIONAL THERAPY 51 52 SPEECH PATHOLOGY 52 53 ELECTROCARDIOLOGY 31827 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PAT 113867 55 56 DRUGS CHARGED TO PATIENTS 452732 1301 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 60 61 EMERGENCY 545099 61 62 OBSERVATION BEDS (NON-DISTINCT 488814 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 65.01 AMBULANCE CHARGES (S-2 LINE 56. 65.01 65.02 AMBULANCE CHARGES (S-2 LINE 56. 65.02 65.03 AMBULANCE CHARGES (S-2 LINE 56. 65.03 101 SUBTOTAL 3581200 2126 101 102 CRNA CHARGES 102 103 LESS PBP CLINIC LAB SERV-PGM ONLY CHRGS 103 104 NET CHARGES 3581200 2126 104 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:18 APPORTIONMENT OF INPATIENT ROUTINE SERVICE CAPITAL COSTS WORKSHEET D PART I CHECK [ ] TITLE V APPLICABLE [ ] TITLE XVIII-PT A BOXES [XX] TITLE XIX ---------- OLD CAPITAL ---------- ---------- NEW CAPITAL ---------- REDUCED REDUCED CAPITAL SWING-BED CAPITAL CAPITAL SWING-BED CAPITAL COST CENTER DESCRIPTION RELATED ADJUSTMENT RELATED RELATED ADJUSTMENT RELATED COST COST COST COST 1 2 3 4 5 6 INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 607833 607833 25 26 INTENSIVE CARE UNIT 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 31 33 NURSERY 12536 12536 33 101 TOTAL 620369 620369 101 ---- OLD CAPITAL ---- ---- NEW CAPITAL ---- INPATIENT INPATIENT TOTAL INPATIENT PER PROGRAM PER PROGRAM COST CENTER DESCRIPTION PATIENT PROGRAM DIEM CAPITAL DIEM CAPITAL DAYS DAYS COST COST 7 8 9 10 11 12 INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 7799 465 77.94 36242 25 26 INTENSIVE CARE UNIT 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 31 33 NURSERY 641 19.56 33 101 TOTAL 8440 465 36242 101 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS WORKSHEET D PART II CHECK [ ] TITLE V [XX] HOSPITAL (15-0146) [ ] SUB III [XX] PPS APPLICABLE [ ] TITLE XVIII-PT A [ ] SUB I [ ] SUB IV [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [ ] OTHER OLD NEW ---- OLD CAPITAL ---- ---- NEW CAPITAL ---- CAPITAL CAPITAL INPATIENT RATIO OF RATIO OF COST CENTER DESCRIPTION RELATED RELATED TOTAL PROGRAM COST TO CAPITAL COST TO CAPITAL COST COST CHARGES CHARGES CHARGES COSTS CHARGES COSTS 1 2 3 4 5 6 7 8 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 839384 6300635 121532 .133222 16191 37 39 DELIVERY ROOM & LABOR ROOM 35944 449090 .080037 39 40 ANESTHESIOLOGY 58114 541579 84085 .107305 9023 40 41 RADIOLOGY-DIAGNOSTIC 1498560 23346051 153978 .064189 9884 41 41.01 CAT SCAN 41.01 44 LABORATORY 79464 12333661 180159 .006443 1161 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 47 BLOOD STORING, PROCESSING & T 1904 165154 3163 .011529 36 47 49 RESPIRATORY THERAPY 127152 2476201 52502 .051350 2696 49 50 PHYSICAL THERAPY 49132 1149625 6988 .042737 299 50 51 OCCUPATIONAL THERAPY 3501 553402 1540 .006326 10 51 52 SPEECH PATHOLOGY 1823 203864 .008942 52 53 ELECTROCARDIOLOGY 4959 1424361 18137 .003482 63 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO P 82422 3779512 84906 .021808 1852 55 56 DRUGS CHARGED TO PATIENTS 64193 7963742 250465 .008061 2019 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 107 20234 .005288 60 61 EMERGENCY 261993 12428018 .021081 61 62 OBSERVATION BEDS (NON-DISTINC 151743 1401788 .108250 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 3260395 74536917 957455 43234 101 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 APPORTIONMENT OF INPATIENT ROUTINE SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART III CHECK [ ] TITLE V APPLICABLE [ ] TITLE XVIII-PT A BOXES [XX] TITLE XIX INPATIENT NONPHYSICIAN MEDICAL SWING-BED TOTAL INPATIENT PROGRAM COST CENTER DESCRIPTION ANESTHETIST EDUCATION ADJUSTMENT TOTAL PATIENT PER PROGRAM PASS THRU COST COST AMOUNT COSTS DAYS DIEM DAYS COSTS 1 2 3 4 5 6 7 8 INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 7799 465 25 26 INTENSIVE CARE UNIT 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 31 33 NURSERY 641 33 34 SKILLED NURSING FACILITY 34 35 NURSING FACILITY 35 101 TOTAL 8440 465 101 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:18 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV CHECK [ ] TITLE V [XX] HOSPITAL (15-0146) [ ] SUB IV [ ] PPS APPLICABLE [ ] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [ ] NF [ ] OTHER [ ] SUB III [ ] ICF/MR OUTPATIENT NONPHYSICIAN NONPHYSICIAN MEDICAL COST CENTER DESCRIPTION ANESTHETIST ANESTHETIST EDUCATION TOTAL COST COST COST N/A N/A N/A COSTS 1 1.01 2 2.01 2.02 2.03 3 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 37 39 DELIVERY ROOM & LABOR ROOM 39 40 ANESTHESIOLOGY 40 41 RADIOLOGY-DIAGNOSTIC 41 41.01 CAT SCAN 41.01 44 LABORATORY 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 47 BLOOD STORING, PROCESSING & T 47 49 RESPIRATORY THERAPY 49 50 PHYSICAL THERAPY 50 51 OCCUPATIONAL THERAPY 51 52 SPEECH PATHOLOGY 52 53 ELECTROCARDIOLOGY 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO P 55 56 DRUGS CHARGED TO PATIENTS 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 60 61 EMERGENCY 61 62 OBSERVATION BEDS (NON-DISTINC 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 101 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:18 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV CHECK [ ] TITLE V [XX] HOSPITAL (15-0146) [ ] SUB IV [ ] PPS APPLICABLE [ ] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [ ] NF [ ] OTHER [ ] SUB III [ ] ICF/MR INPATIENT OUTPATIENT RATIO OF OUTPATIENT INPATIENT PROGRAM OUTPATIENT COST CENTER DESCRIPTION PASS THROUGH TOTAL COST TO RATIO OF COST PROGRAM PASS THROUGH PROGRAM COSTS CHARGES CHARGES TO CHARGES CHARGES COSTS CHARGES 3.01 4 5 5.01 6 7 8 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 6300635 121532 37 39 DELIVERY ROOM & LABOR ROOM 449090 39 40 ANESTHESIOLOGY 541579 84085 40 41 RADIOLOGY-DIAGNOSTIC 23346051 153978 41 41.01 CAT SCAN 41.01 44 LABORATORY 12333661 180159 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 47 BLOOD STORING, PROCESSING & T 165154 3163 47 49 RESPIRATORY THERAPY 2476201 52502 49 50 PHYSICAL THERAPY 1149625 6988 50 51 OCCUPATIONAL THERAPY 553402 1540 51 52 SPEECH PATHOLOGY 203864 52 53 ELECTROCARDIOLOGY 1424361 18137 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO P 3779512 84906 55 56 DRUGS CHARGED TO PATIENTS 7963742 250465 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 20234 60 61 EMERGENCY 12428018 61 62 OBSERVATION BEDS (NON-DISTINC 1401788 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 74536917 957455 101 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:18 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV CHECK [ ] TITLE V [XX] HOSPITAL (15-0146) [ ] SUB IV [ ] PPS APPLICABLE [ ] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [ ] NF [ ] OTHER [ ] SUB III [ ] ICF/MR OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT PROGRAM PROGRAM PROGRAM COST CENTER DESCRIPTION PROGRAM PROGRAM PASS THROUGH PASS THROUGH PASS THROUGH CHARGES CHARGES COSTS COSTS COSTS 8.01 8.02 9 9.01 9.02 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 37 39 DELIVERY ROOM & LABOR ROOM 39 40 ANESTHESIOLOGY 40 41 RADIOLOGY-DIAGNOSTIC 41 41.01 CAT SCAN 41.01 44 LABORATORY 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 47 BLOOD STORING, PROCESSING & T 47 49 RESPIRATORY THERAPY 49 50 PHYSICAL THERAPY 50 51 OCCUPATIONAL THERAPY 51 52 SPEECH PATHOLOGY 52 53 ELECTROCARDIOLOGY 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO P 55 56 DRUGS CHARGED TO PATIENTS 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 60 61 EMERGENCY 61 62 OBSERVATION BEDS (NON-DISTINC 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 101 TOTAL 101 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/29/2009 10:18 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI CHECK [ ] TITLE V - O/P [XX] HOSPITAL (15-0146) [ ] SNF APPLICABLE [ ] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [XX] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR --------- PROGRAM CHARGES ---------- OUTPATIENT COST TO CHARGE RATIO FROM WORKSHEET C, AMBULATORY OTHER COST CENTER DESCRIPTION PART II PART I PART II SURGICAL OUTPATIENT OUTPATIENT COL. 8 COL. 9 COL. 9 CENTER RADIOLOGY DIAGNOSTIC 1 1.01 1.02 2 3 4 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM .594138 .594138 .594138 37 39 DELIVERY ROOM & LABOR ROOM .215340 .215340 .215340 39 40 ANESTHESIOLOGY .289762 .289762 .289762 40 41 RADIOLOGY-DIAGNOSTIC .191092 .191092 .191092 41 41.01 CAT SCAN 41.01 44 LABORATORY .209685 .209685 .209685 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA .771141 .771141 .771141 47 49 RESPIRATORY THERAPY .422763 .422763 .422763 49 50 PHYSICAL THERAPY .610200 .610200 .610200 50 51 OCCUPATIONAL THERAPY .378625 .378625 .378625 51 52 SPEECH PATHOLOGY .544971 .544971 .544971 52 53 ELECTROCARDIOLOGY .085976 .085976 .085976 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PAT .356401 .356401 .356401 55 56 DRUGS CHARGED TO PATIENTS .269234 .269234 .269234 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC .292181 .292181 .292181 60 61 EMERGENCY .223557 .223557 .223557 61 62 OBSERVATION BEDS (NON-DISTINCT 1.163835 1.163835 1.163835 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES .654298 .654298 .654298 65 65.01 AMBULANCE CHARGES (S-2 LINE 56. .654298 .654298 65.01 65.02 AMBULANCE CHARGES (S-2 LINE 56. .654298 .654298 65.02 65.03 AMBULANCE CHARGES (S-2 LINE 56. .654298 .654298 65.03 101 SUBTOTAL 101 102 CRNA CHARGES 102 103 LESS PBP CLINIC LAB SERV-PGM ONLY CHRGS 103 104 NET CHARGES 104 PART VI - VACCINE COST APPORTIONMENT 1 1 DRUGS CHARGED TO PATIENTS - RATIO OF COST TO CHARGES .269234 1 2 PROGRAM VACCINE CHARGES 2 2.01 PROGRAM VACCINE CHARGES 2.01 3 PROGRAM COSTS 3 3.01 PROGRAM COSTS 3.01 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/29/2009 10:18 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI CHECK [ ] TITLE V - O/P [XX] HOSPITAL (15-0146) [ ] SNF APPLICABLE [ ] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [XX] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR ------------------ PROGRAM CHARGES ------------------- --------- PROGRAM COST --------- ALL PPS SER- PPS SER- PPS SER- OUTPATIENT OTHER (1) VICES ALL OTHER VICES VICES AMBULATORY OTHER COST CENTER DESCRIPTION (SEE (SEE (SEE (SEE (SEE SURGICAL OUTPATIENT OUTPATIENT INSTRU.) INSTRU.) INSTRU.) INSTRU.) INSTRU.) CENTER RADIOLOGY DIAGNOSTIC 5 5.01 5.02 5.03 5.04 6 7 8 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 121250 37 39 DELIVERY ROOM & LABOR ROOM 39 40 ANESTHESIOLOGY 825254 40 41 RADIOLOGY-DIAGNOSTIC 1043752 41 41.01 CAT SCAN 41.01 44 LABORATORY 533608 44 46.30 BLOOD CLOTTING FACTORS ADMIN C 46.30 47 BLOOD STORING, PROCESSING & TR 2622 47 49 RESPIRATORY THERAPY 93789 49 50 PHYSICAL THERAPY 36001 50 51 OCCUPATIONAL THERAPY 8567 51 52 SPEECH PATHOLOGY 7481 52 53 ELECTROCARDIOLOGY 46178 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PA 72988 55 56 DRUGS CHARGED TO PATIENTS 238962 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 60 61 EMERGENCY 61 62 OBSERVATION BEDS (NON-DISTINCT 132034 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 302132 65 65.01 AMBULANCE CHARGES (S-2 LINE 56 65.01 65.02 AMBULANCE CHARGES (S-2 LINE 56 65.02 65.03 AMBULANCE CHARGES (S-2 LINE 56 65.03 101 SUBTOTAL 3464618 101 102 CRNA CHARGES 102 103 PBP CLINIC LAB 103 104 NET CHARGES 3464618 104 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/29/2009 10:18 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI CHECK [ ] TITLE V - O/P [XX] HOSPITAL (15-0146) [ ] SNF APPLICABLE [ ] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [XX] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR -------------------- PROGRAM COST -------------------- HOSPITAL HOSPITAL PPS PPS PPS I/P PART B I/P PART B SERVICES ALL OTHER SERVICES SERVICES CHARGES COST COST CENTER DESCRIPTION ALL OTHER (COLUMNS (COLUMNS (COLUMNS (COLUMNS (SEE (COLUMNS (COLS 1x5) 1.01x5.01) 1.01x5.02) 1.01x5.03 1.01x5.04 INSTRU.) 1.02x10) 9 9.01 9.02 9.03 9.04 10 11 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 72039 37 39 DELIVERY ROOM & LABOR ROOM 39 40 ANESTHESIOLOGY 239127 40 41 RADIOLOGY-DIAGNOSTIC 199453 41 41.01 CAT SCAN 41.01 44 LABORATORY 111890 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA 2022 47 49 RESPIRATORY THERAPY 39651 49 50 PHYSICAL THERAPY 21968 50 51 OCCUPATIONAL THERAPY 3244 51 52 SPEECH PATHOLOGY 4077 52 53 ELECTROCARDIOLOGY 3970 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PAT 26013 55 56 DRUGS CHARGED TO PATIENTS 64337 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 60 61 EMERGENCY 61 62 OBSERVATION BEDS (NON-DISTINCT 153666 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 197684 65 65.01 AMBULANCE CHARGES (S-2 LINE 56. 65.01 65.02 AMBULANCE CHARGES (S-2 LINE 56. 65.02 65.03 AMBULANCE CHARGES (S-2 LINE 56. 65.03 101 SUBTOTAL 1139141 101 102 CRNA CHARGES 102 103 LESS PBP CLINIC LAB SERV-PGM ONLY CHRGS 103 104 NET CHARGES 1139141 104 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART I [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT PART I - ALL PROVIDER COMPONENTS HOSPITAL SUB I SUB II SUB III SUB IV SNF (PPS) (15-0146) INPATIENT DAYS 1 1 1 1 1 1 1 INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS AND SWING-BED DAYS 7799 1 EXCLUDING NEWBORN) 2 INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS, EXCLUDING SWING 7799 2 BED AND NEWBORN DAYS) 3 PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 5852 3 4 SEMI-PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 1947 4 5 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE 5 ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 6 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE 6 ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 7 TOTAL SWING-BED NF-TYPE INPATIENT DAYS (INCL PRIVATE 7 ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 8 TOTAL SWING-BED NF-TYPE INPATIENT DAYS (INCL PRIVATE 8 ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 9 INPATIENT DAYS INCLUDING PRIVATE ROOM DAYS APPLICABLE TO THE 2714 9 PROGRAM (EXCLUDING SWING-BED AND NEWBORN DAYS) 10 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII 10 ONLY (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 11 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII 11 ONLY (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 12 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V OR XIX 12 ONLY (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 13 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V OR XIX 13 ONLY (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 14 MEDICALLY NECESSARY PRIVATE ROOM DAYS APPLICABLE TO THE 14 PROGRAM (EXCLUDING SWING-BED DAYS) 15 TOTAL NURSERY DAYS 15 16 TITLE V OR XIX NURSERY DAYS 16 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART I (CONT) [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT PART I - ALL PROVIDER COMPONENTS HOSPITAL SUB I SUB II SUB III SUB IV SNF (PPS) (15-0146) SWING-BED ADJUSTMENT 1 1 1 1 1 1 17 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO 17 SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 18 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO 18 SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 19 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO 19 SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 20 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO 20 SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 21 TOTAL GENERAL INPATIENT ROUTINE SERVICE COST 6535037 21 22 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES THROUGH 22 DECEMBER 31 OF THE COST REPORTING PERIOD 23 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES AFTER 23 DECEMBER 31 OF THE COST REPORTING PERIOD 24 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES THROUGH 24 DECEMBER 31 OF THE COST REPORTING PERIOD 25 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES AFTER 25 DECEMBER 31 OF THE COST REPORTING PERIOD 26 TOTAL SWING-BED COST 26 27 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST 6535037 27 PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 GENERAL INPATIENT ROUTINE SERVICE CHARGES 7839381 28 (EXCLUDING SWING-BED CHARGES) 29 PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 7839381 29 30 SEMI-PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 30 31 GENERAL INPATIENT ROUTINE SERVICE COST/CHARGE RATIO .833616 31 32 AVERAGE PRIVATE ROOM PER DIEM CHARGE 1339.61 32 33 AVERAGE SEMI-PRIVATE ROOM PER DIEM CHARGE 33 34 AVERAGE PER DIEM PRIVATE ROOM CHARGE DIFFERENTIAL 1339.61 34 35 AVERAGE PER DIEM PRIVATE ROOM COST DIFFERENTIAL 1116.72 35 36 PRIVATE ROOM COST DIFFERENTIAL ADJUSTMENT 6535037 36 37 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST 37 AND PRIVATE ROOM COST DIFFERENTIAL PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART II [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT PART II - HOSPITAL AND SUBPROVIDERS ONLY HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0146) PROGRAM INPATIENT OPERATING COST BEFORE 1 1 1 1 1 PASS THROUGH COST ADJUSTMENTS 38 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 837.93 38 39 PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 2274142 39 40 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO THE PROGRAM 40 41 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 2274142 41 TOTAL TOTAL AVERAGE PROGRAM PROGRAM I/P COST I/P DAYS PER DIEM DAYS COST 1 2 3 4 5 42 NURSERY (TITLES V AND XIX ONLY) 42 INTENSIVE CARE TYPE INPATIENT HOSPITAL UNITS 43 INTENSIVE CARE UNIT 43 44 CORONARY CARE UNIT 44 45 BURN INTENSIVE CARE UNIT 45 46 SURGICAL INTENSIVE CARE UNIT 46 47 OTHER SPECIAL CARE (SPECIFY) 47 HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0146) 1 1 1 1 1 48 PROGRAM INPATIENT ANCILLARY SERVICE COST 2137556 48 49 TOTAL PROGRAM INPATIENT COSTS 4411698 49 PASS THROUGH COST ADJUSTMENTS 50 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT ROUTINE 211529 50 SERVICES 51 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT 251156 51 ANCILLARY SERVICES 52 TOTAL PROGRAM EXCLUDABLE COST 462685 52 53 TOTAL PROGRAM INPATIENT OPERATING COST EXCLUDING CAPITAL 3949013 53 RELATED, NONPHYSICIAN ANESTHETIST AND MEDICAL EDUCATION COSTS PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART II (CONT) [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT PART II - HOSPITAL AND SUBPROVIDERS ONLY HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0146) TARGET AMOUNT AND LIMITATION COMPUTATION 1 1 1 1 1 54 PROGRAM DISCHARGES 54 55 TARGET AMOUNT PER DISCHARGE 55 56 TARGET AMOUNT 56 57 DIFFERENCE BETWEEN ADJUSTED INPATIENT OPERATING COST AND 57 TARGET AMOUNT 58 BONUS PAYMENT 58 58.01 LESSER OF LINE 53/LINE 54 OR LINE 55 FROM THE COST REPORTING 58.01 PERIOD ENDING 1996, UPDATED & COMPOUNDED BY THE MARKET BASKET 58.02 LESSER OF LINE 53/LINE 54 OR LINE 55 FROM PRIOR YEAR COST 58.02 REPORT UPDATED BY THE MARKET BASKET 58.03 IF LINE 53/LINE 54 IS LESS THAN THE LOWER OF LINES 55, 58.01 58.03 OR 58.02, THE LESSER OF 50% OF THE AMOUNT BY WHICH OPERATING COSTS ARE LESS THAN EXPECTED COSTS, OR 1% OF THE TARGET AMOUNT 58.04 RELIEF PAYMENT 58.04 59 ALLOWABLE INPATIENT COST PLUS INCENTIVE PAYMENT 59 59.01 ALLOWABLE INPATIENT COST PER DISCHARGE (LTCH ONLY) 59.01 59.02 PROGRAM DISCHARGES PRIOR TO JULY 1 59.02 59.03 PROGRAM DISCHARGES AFTER JULY 1 59.03 59.04 PROGRAM DISCHARGES (SEE INSTRUCTIONS) 59.04 59.05 REDUCED INPAT COST PER DISCH. FOR DISCHARGES PRIOR TO JULY 1 59.05 59.06 REDUCED INPAT COST PER DISCHARGE FOR DISCHARGES AFTER JULY 1 59.06 59.07 REDUCED INPAT COST PER DISCHARGE (SEE INSTR.) (LTCH ONLY) 59.07 59.08 REDUCED INPATIENT COST PLUS INCENTIVE PAYMENT (SEE INSTR.) 59.08 PROGRAM INPATIENT ROUTINE SWING BED COST 60 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS THROUGH 60 DECEMBER 31 OF THE COST REPORTING PERIOD 61 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS AFTER 61 DECEMBER 31 OF THE COST REPORTING PERIOD 62 TOTAL MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS 62 63 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS THROUGH 63 DECEMBER 31 OF THE COST REPORTING PERIOD 64 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS AFTER 64 DECEMBER 31 OF THE COST REPORTING PERIOD 65 TOTAL TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS 65 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PARTS III & IV [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT PART III - SKILLED NURSING FACILITY, NURSING FACILITY AND ICF/MR ONLY SNF 1 66 SNF/NF/ICF/MR ROUTINE SERVICE COST 66 67 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 67 68 PROGRAM ROUTINE SERVICE COST 68 69 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO PROGRAM 69 70 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COSTS 70 71 CAPITAL RELATED COST ALLOCATED TO INPATIENT ROUTINE SERV COSTS 71 72 PER DIEM CAPITAL RELATED COSTS 72 73 PROGRAM CAPITAL RELATED COSTS 73 74 INPATIENT ROUTINE SERVICE COST 74 75 AGGREGATE CHARGES TO BENEFICIARIES FOR EXCESS COSTS 75 76 TOTAL PGM ROUTINE SERVICE COSTS FOR COMPARISON TO COST LIMIT 76 77 INPATIENT ROUTINE SERVICE COST PER DIEM LIMITATION 77 78 INPATIENT ROUTINE SERVICE COST LIMITATION 78 79 REASONABLE INPATIENT ROUTINE SERVICE COSTS 79 80 PROGRAM INPATIENT ANCILLARY SERVICES 80 81 UTILIZATION REVIEW--PHYSICIAN COMPENSATION 81 82 TOTAL PROGRAM INPATIENT OPERATING COSTS 82 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PARTS III & IV [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0146) 1 1 1 1 1 PART IV - COMPUTATION OF OBSERVATION BED COST 83 TOTAL OBSERVATION BEDS 1947 83 84 ADJUSTED GENERAL INPATIENT ROUTINE COST PER DIEM 837.93 84 85 OBSERVATION BED COST 1631450 85 COMPUTATION OF OBSERVATION BED PASS THROUGH COST - HOSPITAL TOTAL ROUTINE COLUMN 1 OBSERVATION OBSERVATION BED COST DIVIDED BY BED COST PASS-THROUGH COST COST (FROM LINE 27) COLUMN 2 (FROM LINE 85) COL 3 TIMES COL 4 1 2 3 4 5 86 OLD CAPITAL-RELATED COST 6535037 1631450 86 87 NEW CAPITAL-RELATED COST 607833 6535037 .093011 1631450 151743 87 88 NON PHYSICIAN ANESTHETIST 6535037 1631450 88 89 MEDICAL EDUCATION 6535037 1631450 89 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART I [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT PART I - ALL PROVIDER COMPONENTS HOSPITAL SUB I SUB II SUB III SUB IV NF (PPS) (15-0146) INPATIENT DAYS 1 1 1 1 1 1 1 INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS AND SWING-BED DAYS 7799 1 EXCLUDING NEWBORN) 2 INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS, EXCLUDING SWING 7799 2 BED AND NEWBORN DAYS) 3 PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 5852 3 4 SEMI-PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 1947 4 5 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE 5 ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 6 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE 6 ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 7 TOTAL SWING-BED NF-TYPE INPATIENT DAYS (INCL PRIVATE 7 ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 8 TOTAL SWING-BED NF-TYPE INPATIENT DAYS (INCL PRIVATE 8 ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 9 INPATIENT DAYS INCLUDING PRIVATE ROOM DAYS APPLICABLE TO THE 465 9 PROGRAM (EXCLUDING SWING-BED AND NEWBORN DAYS) 10 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII 10 ONLY (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 11 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII 11 ONLY (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 12 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V OR XIX 12 ONLY (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 13 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V OR XIX 13 ONLY (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 14 MEDICALLY NECESSARY PRIVATE ROOM DAYS APPLICABLE TO THE 14 PROGRAM (EXCLUDING SWING-BED DAYS) 15 TOTAL NURSERY DAYS 641 15 16 TITLE V OR XIX NURSERY DAYS 16 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART I (CONT) [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT PART I - ALL PROVIDER COMPONENTS HOSPITAL SUB I SUB II SUB III SUB IV NF (PPS) (15-0146) SWING-BED ADJUSTMENT 1 1 1 1 1 1 17 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO 17 SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 18 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO 18 SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 19 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO 19 SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 20 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO 20 SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 21 TOTAL GENERAL INPATIENT ROUTINE SERVICE COST 6535037 21 22 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES THROUGH 22 DECEMBER 31 OF THE COST REPORTING PERIOD 23 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES AFTER 23 DECEMBER 31 OF THE COST REPORTING PERIOD 24 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES THROUGH 24 DECEMBER 31 OF THE COST REPORTING PERIOD 25 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES AFTER 25 DECEMBER 31 OF THE COST REPORTING PERIOD 26 TOTAL SWING-BED COST 26 27 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST 6535037 27 PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 GENERAL INPATIENT ROUTINE SERVICE CHARGES 7839381 28 (EXCLUDING SWING-BED CHARGES) 29 PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 7839381 29 30 SEMI-PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 30 31 GENERAL INPATIENT ROUTINE SERVICE COST/CHARGE RATIO .833616 31 32 AVERAGE PRIVATE ROOM PER DIEM CHARGE 1339.61 32 33 AVERAGE SEMI-PRIVATE ROOM PER DIEM CHARGE 33 34 AVERAGE PER DIEM PRIVATE ROOM CHARGE DIFFERENTIAL 1339.61 34 35 AVERAGE PER DIEM PRIVATE ROOM COST DIFFERENTIAL 1116.72 35 36 PRIVATE ROOM COST DIFFERENTIAL ADJUSTMENT 6535037 36 37 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST 37 AND PRIVATE ROOM COST DIFFERENTIAL PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART II [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT PART II - HOSPITAL AND SUBPROVIDERS ONLY HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0146) PROGRAM INPATIENT OPERATING COST BEFORE 1 1 1 1 1 PASS THROUGH COST ADJUSTMENTS 38 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 837.93 38 39 PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 389637 39 40 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO THE PROGRAM 40 41 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 389637 41 TOTAL TOTAL AVERAGE PROGRAM PROGRAM I/P COST I/P DAYS PER DIEM DAYS COST 1 2 3 4 5 42 NURSERY (TITLES V AND XIX ONLY) 28428 641 44.35 42 INTENSIVE CARE TYPE INPATIENT HOSPITAL UNITS 43 INTENSIVE CARE UNIT 43 44 CORONARY CARE UNIT 44 45 BURN INTENSIVE CARE UNIT 45 46 SURGICAL INTENSIVE CARE UNIT 46 47 OTHER SPECIAL CARE (SPECIFY) 47 HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0146) 1 1 1 1 1 48 PROGRAM INPATIENT ANCILLARY SERVICE COST 294841 48 49 TOTAL PROGRAM INPATIENT COSTS 684478 49 PASS THROUGH COST ADJUSTMENTS 50 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT ROUTINE 36242 50 SERVICES 51 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT 43234 51 ANCILLARY SERVICES 52 TOTAL PROGRAM EXCLUDABLE COST 79476 52 53 TOTAL PROGRAM INPATIENT OPERATING COST EXCLUDING CAPITAL 605002 53 RELATED, NONPHYSICIAN ANESTHETIST AND MEDICAL EDUCATION COSTS PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART II (CONT) [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT PART II - HOSPITAL AND SUBPROVIDERS ONLY HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0146) TARGET AMOUNT AND LIMITATION COMPUTATION 1 1 1 1 1 54 PROGRAM DISCHARGES 54 55 TARGET AMOUNT PER DISCHARGE 55 56 TARGET AMOUNT 56 57 DIFFERENCE BETWEEN ADJUSTED INPATIENT OPERATING COST AND 57 TARGET AMOUNT 58 BONUS PAYMENT 58 58.01 LESSER OF LINE 53/LINE 54 OR LINE 55 FROM THE COST REPORTING 58.01 PERIOD ENDING 1996, UPDATED & COMPOUNDED BY THE MARKET BASKET 58.02 LESSER OF LINE 53/LINE 54 OR LINE 55 FROM PRIOR YEAR COST 58.02 REPORT UPDATED BY THE MARKET BASKET 58.03 IF LINE 53/LINE 54 IS LESS THAN THE LOWER OF LINES 55, 58.01 58.03 OR 58.02, THE LESSER OF 50% OF THE AMOUNT BY WHICH OPERATING COSTS ARE LESS THAN EXPECTED COSTS, OR 1% OF THE TARGET AMOUNT 58.04 RELIEF PAYMENT 58.04 59 ALLOWABLE INPATIENT COST PLUS INCENTIVE PAYMENT 59 59.01 ALLOWABLE INPATIENT COST PER DISCHARGE (LTCH ONLY) 59.01 59.02 PROGRAM DISCHARGES PRIOR TO JULY 1 59.02 59.03 PROGRAM DISCHARGES AFTER JULY 1 59.03 59.04 PROGRAM DISCHARGES (SEE INSTRUCTIONS) 59.04 59.05 REDUCED INPAT COST PER DISCH. FOR DISCHARGES PRIOR TO JULY 1 59.05 59.06 REDUCED INPAT COST PER DISCHARGE FOR DISCHARGES AFTER JULY 1 59.06 59.07 REDUCED INPAT COST PER DISCHARGE (SEE INSTR.) (LTCH ONLY) 59.07 59.08 REDUCED INPATIENT COST PLUS INCENTIVE PAYMENT (SEE INSTR.) 59.08 PROGRAM INPATIENT ROUTINE SWING BED COST 60 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS THROUGH 60 DECEMBER 31 OF THE COST REPORTING PERIOD 61 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS AFTER 61 DECEMBER 31 OF THE COST REPORTING PERIOD 62 TOTAL MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS 62 63 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS THROUGH 63 DECEMBER 31 OF THE COST REPORTING PERIOD 64 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS AFTER 64 DECEMBER 31 OF THE COST REPORTING PERIOD 65 TOTAL TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS 65 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PARTS III & IV [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT PART III - SKILLED NURSING FACILITY, NURSING FACILITY AND ICF/MR ONLY NF 1 66 SNF/NF/ICF/MR ROUTINE SERVICE COST 66 67 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 67 68 PROGRAM ROUTINE SERVICE COST 68 69 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO PROGRAM 69 70 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COSTS 70 71 CAPITAL RELATED COST ALLOCATED TO INPATIENT ROUTINE SERV COSTS 71 72 PER DIEM CAPITAL RELATED COSTS 72 73 PROGRAM CAPITAL RELATED COSTS 73 74 INPATIENT ROUTINE SERVICE COST 74 75 AGGREGATE CHARGES TO BENEFICIARIES FOR EXCESS COSTS 75 76 TOTAL PGM ROUTINE SERVICE COSTS FOR COMPARISON TO COST LIMIT 76 77 INPATIENT ROUTINE SERVICE COST PER DIEM LIMITATION 77 78 INPATIENT ROUTINE SERVICE COST LIMITATION 78 79 REASONABLE INPATIENT ROUTINE SERVICE COSTS 79 80 PROGRAM INPATIENT ANCILLARY SERVICES 80 81 UTILIZATION REVIEW--PHYSICIAN COMPENSATION 81 82 TOTAL PROGRAM INPATIENT OPERATING COSTS 82 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PARTS III & IV [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (15-0146) 1 1 1 1 1 PART IV - COMPUTATION OF OBSERVATION BED COST 83 TOTAL OBSERVATION BEDS 1947 83 84 ADJUSTED GENERAL INPATIENT ROUTINE COST PER DIEM 837.93 84 85 OBSERVATION BED COST 1631450 85 COMPUTATION OF OBSERVATION BED PASS THROUGH COST - HOSPITAL TOTAL ROUTINE COLUMN 1 OBSERVATION OBSERVATION BED COST DIVIDED BY BED COST PASS-THROUGH COST COST (FROM LINE 27) COLUMN 2 (FROM LINE 85) COL 3 TIMES COL 4 1 2 3 4 5 86 OLD CAPITAL-RELATED COST 6535037 1631450 86 87 NEW CAPITAL-RELATED COST 607833 6535037 .093011 1631450 151743 87 88 NON PHYSICIAN ANESTHETIST 6535037 1631450 88 89 MEDICAL EDUCATION 6535037 1631450 89 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 INPATIENT ANCILLARY COST APPORTIONMENT WORKSHEET D-4 [ ] TITLE V [XX] HOSPITAL (15-0146) [ ] SNF [XX] PPS [XX] TITLE XVIII-PT A [ ] SUB I [ ] NF [ ] TEFRA [ ] TITLE XIX [ ] SUB II [ ] S/B-SNF [ ] OTHER [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR RATIO OF COST INPATIENT INPATIENT COST CENTER DESCRIPTION TO CHARGES PROGRAM CHARGES PROGRAM COSTS 1 2 3 INPATIENT ROUTINE SERVICE COST CENTERS 25 ADULTS & PEDIATRICS 3365674 25 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM .594138 398347 236673 37 39 DELIVERY ROOM & LABOR ROOM .215340 39 40 ANESTHESIOLOGY .317505 48999 15557 40 41 RADIOLOGY-DIAGNOSTIC .191092 1536023 293522 41 41.01 CAT SCAN 41.01 44 LABORATORY .209685 1467131 307635 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA .771141 40400 31154 47 49 RESPIRATORY THERAPY .422763 636987 269295 49 50 PHYSICAL THERAPY .610200 115949 70752 50 51 OCCUPATIONAL THERAPY .378625 38611 14619 51 52 SPEECH PATHOLOGY .544971 22985 12526 52 53 ELECTROCARDIOLOGY .085976 265165 22798 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PAT .356401 647551 230788 55 56 DRUGS CHARGED TO PATIENTS .269234 1642718 442276 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC .292181 60 61 EMERGENCY .223557 849721 189961 61 62 OBSERVATION BEDS (NON-DISTINCT 1.163835 62 OTHER REIMBURSABLE COST CENTERS 63.50 RHC 63.50 63.60 FQHC 63.60 65 AMBULANCE SERVICES 65 101 TOTAL 7710587 2137556 101 102 LESS PBP CLINIC LAB SVCS-PGM ONLY CHARGES 102 103 NET CHARGES 7710587 103 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 INPATIENT ANCILLARY COST APPORTIONMENT WORKSHEET D-4 [ ] TITLE V [XX] HOSPITAL (15-0146) [ ] SNF [XX] PPS [ ] TITLE XVIII-PT A [ ] SUB I [ ] NF [ ] TEFRA [XX] TITLE XIX [ ] SUB II [ ] S/B-SNF [ ] OTHER [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR RATIO OF COST INPATIENT INPATIENT COST CENTER DESCRIPTION TO CHARGES PROGRAM CHARGES PROGRAM COSTS 1 2 3 INPATIENT ROUTINE SERVICE COST CENTERS 25 ADULTS & PEDIATRICS 599796 25 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM .594138 121532 72207 37 39 DELIVERY ROOM & LABOR ROOM .215340 39 40 ANESTHESIOLOGY .317505 84085 26697 40 41 RADIOLOGY-DIAGNOSTIC .191092 153978 29424 41 41.01 CAT SCAN 41.01 44 LABORATORY .209685 180159 37777 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA .771141 3163 2439 47 49 RESPIRATORY THERAPY .422763 52502 22196 49 50 PHYSICAL THERAPY .610200 6988 4264 50 51 OCCUPATIONAL THERAPY .378625 1540 583 51 52 SPEECH PATHOLOGY .544971 52 53 ELECTROCARDIOLOGY .085976 18137 1559 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PAT .356401 84906 30261 55 56 DRUGS CHARGED TO PATIENTS .269234 250465 67434 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC .292181 60 61 EMERGENCY .223557 61 62 OBSERVATION BEDS (NON-DISTINCT 1.163835 62 OTHER REIMBURSABLE COST CENTERS 63.50 RHC 63.50 63.60 FQHC 63.60 65 AMBULANCE SERVICES 65 101 TOTAL 957455 294841 101 102 LESS PBP CLINIC LAB SVCS-PGM ONLY CHARGES 102 103 NET CHARGES 957455 103 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/29/2009 10:18 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART A PART A - INPATIENT HOSPITAL SERVICES UNDER PPS HOSPITAL SUB I SUB II SUB III SUB IV (15-0146) DRG AMOUNT 1 OTHER THAN OUTLIER PAYMENTS OCCURRING BEFORE OCTOBER 1 2875981 1 1.01 OTHER THAN OUTLIER PAYMENTS OCCURRING ON OR AFTER 958661 1.01 OCTOBER 1 AND BEFORE JANUARY 1 1.02 OTHER THAN OUTLIER PAYMENTS OCCURRING ON OR AFTER JAN 1 1.02 MANAGED CARE PATIENTS 1.03 PAYMENTS PRIOR TO MARCH 1 OR OCTOBER 1 1.03 1.04 PAYMENTS ON OR AFTER OCTOBER 1 AND PRIOR TO JANUARY 1 1.04 1.05 PAYMENTS ON OR AFTER JAN 1 BUT BEFORE APR 1/OCT 1 1.05 1.06 ADDITIONAL AMOUNT RECEIVED OR TO BE RECEIVED 1.06 1.07 PAYMENTS FOR DISCHARGES ON OR AFTER APRIL 1, 2001 1.07 THROUGH SEPTEMBER 30, 2001 1.08 SIMULATED PAYMENTS FROM THE PS&R ON OR AFTER 1.08 APRIL 1, 2001 THROUGH SEPTEMBER 30, 2001 2 OUTLIER PAYMENTS PRIOR TO OCTOBER 1, 1997 2 2.01 OUTLIER PAYMENTS ON OR AFTER OCTOBER 1, 1997 8348 2.01 INDIRECT MEDICAL EDUCATION ADJUSTMENT 3 BED DAYS AVAILABLE DIVIDED BY NO. OF DAYS IN CR PERIOD 26.04 3 3.01 NO OF INTERNS & RESIDENTS FROM WORKSHEET S-3, PART I 3.01 3.02 INDIRECT MEDICAL EDUCATION PERCENTAGE 3.02 3.03 INDIRECT MEDICAL EDUCATION ADJUSTMENT 3.03 3.04 FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PGMS FOR THE 3.04 MOST RECENT CR PERIOD ENDING ON OR BEFORE DEC 31, 1996 3.05 FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PGMS WHICH 3.05 MEET THE CRITERIA FOR AN ADD-ON TO THE CAP FOR NEW PROGRAMS IN ACCORDANCE WITH SECTION 1886(d)(5)(B)(viii) 3.06 ADJUSTED FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PGMS 3.06 FOR AFFILIATED PROGRAMS IN ACCORDANCE WITH SECTION 1886(d)(5)(B)(viii) [ FOR CR PERIODS ENDING ] [ ON OR AFTER 7/1/2005 ] [E-3,PT.VI,LN.15][PLUS LN.3.06] 3.07 SUM OF LINES 3.04-3.06 0.00 0.00 3.07 3.08 FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PROGRAMS IN 3.08 THE CURRENT YEAR FROM YOUR RECORDS 3.09 FOR CR PERIODS BEGINNING BEFORE OCTOBER 1, ENTER THE 3.09 PERCENTAGE OF DISCHARGES OCCURRING PRIOR TO OCTOBER 1 3.10 FOR CR PERIODS BEGINNING BEFORE OCTOBER 1, ENTER THE 3.10 PERCENTAGE OF DISCHARGES OCCURRING ON OR AFTER OCT. 1 3.11 FTE COUNT FOR THE PERIOD IDENTIFIED IN LINE 3.09 3.11 3.12 FTE COUNT FOR THE PERIOD IDENTIFIED IN LINE 3.10 3.12 3.13 FTE COUNT FOR RESIDENTS IN DENTAL & PODIATRIC PROGRAMS 3.13 3.14 CURRENT YEAR ALLOWABLE FTE 3.14 3.15 TOTAL ALLOWABLE FTE COUNT FOR THE PRIOR YEAR, IF NONE 3.15 BUT PRIOR YEAR TEACHING WAS IN EFFECT ENTER 1 HERE.. 3.16 TOTAL ALLOWABLE FTE COUNT FOR THE PENULTIMATE YEAR IF 3.16 THAT YEAR ENDED ON OR AFTER SEPTEMBER 30, 1997, OTHERWISE ENTER ZERO. IF THERE WAS NO FTE COUNT IN THIS PERIOD BUT PRIOR YR TEACHING WAS IN EFFECT ENTER 1 HERE.. RES. IN INIT YRS 3.17 SUM OF LINES 3.14 THROUGH 3.16 DIVIDED BY THE 0.00 3.17 NUMBER OF THOSE LINES IN EXCESS OF ZERO PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/29/2009 10:18 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART A PART A - INPATIENT HOSPITAL SERVICES UNDER PPS (CONT) HOSPITAL SUB I SUB II SUB III SUB IV (15-0146) 3.18 CURRENT YEAR RESIDENT TO BED RATIO 3.18 3.19 PRIOR YEAR RESIDENT TO BED RATIO 3.19 3.20 FOR COST REPORTING PERIODS BEGINNING ON OR AFTER 3.20 OCTOBER 1, 1997, ENTER THE LESSER OF LINES 3.18 OR 3.19 3.21 IME PAYMENTS FOR DSCHGS OCCURRING PRIOR TO OCTOBER 1 3.21 3.22 IME PAYMENTS FOR DSCHGS AFTER SEP 30 BUT BEFORE JAN 1 3.22 3.23 IME PAYMENTS FOR DSCHGS OCCURRING ON OR AFTER JANUARY 1 3.23 [SUM OF LINES][PLUS E-3,PT.VI] [ 3.21-3.23 ][ LINE 23 ] 3.24 SUM OF LINES 3.21-3.23 0 0 3.24 DISPROPORTIONATE SHARE ADJUSTMENT 4 PERCENTAGE OF SSI RECIPIENT PATIENT DAYS TO MEDICARE 0.0327 4 PART A PATIENT DAYS 4.01 PERCENTAGE OF MEDICAID PATIENT DAYS TO TOTAL DAYS 0.2056 4.01 4.02 SUM OF 4 AND 4.01 0.2383 4.02 4.03 ALLOWABLE DISPROPORTIONATE SHARE PERCENTAGE 0.0835 4.03 4.04 DISPROPORTIONATE SHARE ADJUSTMENT 320193 4.04 ADDITIONAL PAYMENT FOR HIGH PERCENTAGE OF ESRD BENEFICIARY DISCHARGES 5 TOTAL MEDICARE DISCHARGES ON WKST S-3, PART I EXCLUDING 5 DISCHARGES FOR DRGs 302, 316 AND 317 5.01 TOTAL ESRD MEDICARE DISCHARGES EXCLUDING DRGs 302, 5.01 316 AND 317 5.02 DIVIDE LINE 5.01 BY LINE 5 5.02 5.03 TOTAL MEDICARE ESRD INPATIENT DAYS EXCLUDING DRGs 5.03 302, 316 AND 317 5.04 RATIO OF AVERAGE LENGTH OF STAY TO ONE WEEK 5.04 5.05 AVERAGE WEEKLY COST FOR DIALYSIS TREATMENTS 5.05 5.06 TOTAL ADDITIONAL PAYMENT 5.06 6 SUBTOTAL 4163183 6 7 HOSPITAL SPECIFIC PAYMENTS 7 7.01 HOSPITAL SPECIFIC PAYMENTS (1996 HSR) 7.01 8 TOTAL PAYMENT FOR INPATIENT OPERATING COSTS 4163183 8 9 PAYMENT FOR INPATIENT PROGRAM CAPITAL 324622 9 10 EXCEPTION PAYMENT FOR INPATIENT PROGRAM CAPITAL 10 11 DIRECT GRADUATE MEDICAL EDUCATION PAYMENT 11 11.01 NURSING AND ALLIED HEALTH MANAGED CARE 11.01 11.02 ADD-ON PAYMENT FOR NEW TECHNOLOGIES 11.02 12 NET ORGAN ACQUISITION COST 12 13 COST OF TEACHING PHYSICIANS 13 14 ROUTINE SERVICE OTHER PASS THROUGH COSTS 14 15 ANCILLARY SERVICE OTHER PASS THROUGH COSTS 15 16 TOTAL 4487805 16 17 PRIMARY PAYER PAYMENTS 7235 17 18 TOTAL AMOUNT PAYABLE FOR PROGRAM BENEFICIARIES 4480570 18 19 DEDUCTIBLES BILLED TO PROGRAM BENEFICIARIES 528890 19 20 COINSURANCE BILLED TO PROGRAM BENEFICIARIES 4927 20 21 REIMBURSABLE BAD DEBTS 138681 21 21.01 REDUCED PROGRAM REIMBURSABLE BAD DEBTS 97077 21.01 21.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE BENEFICIARIES 73973 21.02 22 SUBTOTAL 4043830 22 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/29/2009 10:18 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART A PART A - INPATIENT HOSPITAL SERVICES UNDER PPS (CONT) HOSPITAL SUB I SUB II SUB III SUB IV (15-0146) 23 RECOVERY OF EXCESS DEPRECIATION RESULTING FROM PROVIDER 23 TERMINATION OR A DECREASE IN PROGRAM UTILIZATION 24 OTHER ADJUSTMENTS 24 25 AMOUNTS APPLICABLE TO PRIOR COST REPORTING PERIODS 25 RESULTING FROM DISPOSITION OF DEPRECIABLE ASSETS 26 AMOUNT DUE PROVIDER 4043830 26 27 SEQUESTRATION ADJUSTMENT 27 28 INTERIM PAYMENTS 3850913 28 28.01 TENTATIVE SETTLEMENT (FOR FI USE ONLY) 28.01 29 BALANCE DUE PROVIDER (PROGRAM) 192917 29 30 PROTESTED AMOUNTS (NONALLOWABLE COST REPORT ITEMS) 30 IN ACCORDANCE WITH CMS PUB 15-II, SECTION 115.2 TO BE COMPLETED BY INTERMEDIARY 50 OPERATING OUTLIER AMOUNT FROM WKST E, PART A, LINE 2.01 50 51 CAPITAL OUTLIER AMOUNT FROM WKST L, PART I, LINE 3.01 51 52 OPERATING OUTLIER RECONCILIATION AMOUNT (SEE INSTR.) 52 53 CAPITAL OUTLIER RECONILIATION AMOUNT (SEE INSTRUCTIONS) 53 54 THE RATE USED TO CALCULATE THE TIME VALUE OF MONEY 54 55 TIME VALUE OF MONEY (SEE INSTRUCTIONS) 55 56 CAPITAL TIME VALUE OF MONEY (SEE INSTRUCTIONS) 56 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:18 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART B PART B - MEDICAL AND OTHER HEALTH SERVICES HOSPITAL HOSPITAL HOSPITAL (15-0146) (15-0146) (15-0146) 1 1.01 1.02 1 MEDICAL AND OTHER SERVICES 2126 1 1.01 MEDICAL AND OTHER SERVICES RENDERED ON OR 3581200 1.01 AFTER AUGUST 1, 2000 1.02 PPS PAYMENTS RECEIVED INCLUDING OUTLIERS 2592933 1.02 1.03 1996 HOSPITAL SPECIFIC PAYMENT TO COST 0.864 1.03 RATIO 1.04 LINE 1.01 TIMES LINE 1.03 3094157 1.04 1.05 LINE 1.02 DIVIDED BY LINE 1.04 83.80 1.05 1.06 TRANSITIONAL CORRIDOR PAYMENT 426040 1.06 1.07 AMOUNT FROM WORKSHEET D, PART IV, 1.07 COLUMN 9, LINE 101 2 INTERNS AND RESIDENTS 2 3 ORGAN ACQUISITIONS 3 4 COST OF TEACHING PHYSICIANS 4 5 TOTAL COST 2126 5 COMPUTATION OF LESSER OF COST OR CHARGES REASONABLE CHARGES 6 ANCILLARY SERVICE CHARGES 9113 6 7 INTERNS AND RESIDENTS SERVICE CHARGES 7 8 ORGAN ACQUISITION CHARGES 8 9 CHARGES OF PROFESSIONAL SERVICES OF 9 TEACHING PHYSICIANS 10 TOTAL REASONABLE CHARGES 9113 10 CUSTOMARY CHARGES 11 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM 11 PATIENTS LIABLE FOR PAYMENT FOR SERVICES ON A CHARGE BASIS 12 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM 12 PATIENTS LIABLE FOR PAYMENT FOR SERVICES ON A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 13 RATIO OF LINE 11 TO LINE 12 13 14 TOTAL CUSTOMARY CHARGES 9113 14 15 EXCESS OF CUSTOMARY CHGES OVER REASONABLE 6987 15 COST 16 EXCESS OF REASONABLE COST OVER CUSTOMARY 16 CHARGES 17 LESSER OF COST OR CHARGES 2126 17 17.01 TOTAL PPS PAYMENTS 3018973 17.01 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/29/2009 10:18 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART B PART B - MEDICAL AND OTHER HEALTH SERVICES HOSPITAL HOSPITAL HOSPITAL (15-0146) (15-0146) (15-0146) 1 1.01 1.02 COMPUTATION OF REIMBURSEMENT SETTLEMENT 18 DEDUCTIBLES AND COINSURANCE 18 18.01 DEDUCTIBLES AND COINSURANCE RELATING TO 723156 18.01 LINE 17.01 19 SUBTOTAL 2297943 19 20 SUM OF AMOUNTS FROM WKST E, PARTS C,D & E 20 21 DIRECT GRADUATE MEDICAL EDUCATION PAYMENTS 21 22 ESRD DIRECT MEDICAL EDUCATION COSTS 22 23 SUBTOTAL 2297943 23 24 PRIMARY PAYER PAYMENTS 525 24 25 SUBTOTAL 2297418 25 REIMBURSABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES) 26 COMPOSITE RATE ESRD 26 27 BAD DEBTS 158802 27 27.01 REDUCED REIMBURSABLE BAD DEBTS 111161 27.01 27.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE 94654 27.02 BENEFICIARIES (SEE INSTRUCTIONS) 28 SUBTOTAL 2408579 28 29 RECOVERY OF EXCESS DEPRECIATION RESULTING 29 FROM PROVIDER TERMINATION OR A DECREASE IN PROGRAM UTILIZATION 30 OTHER ADJUSTMENTS 30 30.99 OTHER ADJUSTMENTS (MSP-LCC RECONCILIATION 30.99 AMOUNT) 31 AMOUNTS APPLICABLE TO PRIOR COST REPORTING 31 PERIODS RESULTING FROM DISPOSITION OF DEPRECIABLE ASSETS 32 SUBTOTAL 2408579 32 33 SEQUESTRATION ADJUSTMENT 33 34 INTERIM PAYMENTS 2681746 34 34.01 TENTATIVE SETTLEMENT (FOR FI USE ONLY) 34.01 35 BALANCE DUE PROVIDER/PROGRAM -273167 35 36 PROTESTED AMOUNTS (NONALLOWABLE COST 36 REPORT ITEMS) IN ACCORDANCE WITH CMS PUB 15-II, SECTION 115.2 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART C PART C - OUTPATIENT AMBULATORY SURGICAL CENTER [ ] TITLE V [XX] TITLE XVIII [ ] TITLE XIX HOSPITAL (15-0146) OCTOBER 1, 1997 PRIOR TO ON OR AFTER 1 1.01 1 STANDARD OVERHEAD AMOUNTS (ASC FEES) 1 2 DEDUCTIBLES 2 3 SUBTOTAL 3 4 80 PERCENT OF LINE 3 4 5 ASC PORTION OF BLEND 5 6 OUTPATIENT ASC COST 6 COMPUTATION OF LESSER OF COST OR CHARGES 7 TOTAL CHARGES 7 CUSTOMARY CHARGES 8 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES 8 ON A CHARGE BASIS 9 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES 9 ON A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 10 RATIO OF LINE 8 TO LINE 9 10 11 TOTAL CUSTOMARY CHARGES 11 12 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 12 13 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 13 14 LESSER OF COST OR CHARGES 14 COMPUTATION OF REIMBURSEMENT SETTLEMENT 15 DEDUCTIBLES AND COINSURANCE 15 16 TOTAL 16 17 HOSPITAL SPECIFIC PORTION OF BLEND 17 18 ASC BLENDED AMOUNT 18 19 LESSER OF LINES 16 OR 18 19 20 PART B DEDUCTIBLES AND COINSURANCE 20 21 ASC PAYMENT AMOUNT 21 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART D PART D - OUTPATIENT RADIOLOGY SERVICES [ ] TITLE V [XX] TITLE XVIII [ ] TITLE XIX HOSPITAL (15-0146) OCTOBER 1, 1997 PRIOR TO ON OR AFTER 1 1.01 1 PREVAILING CHARGES 1 2 62 PERCENT OF LINE 1 2 3 DEDUCTIBLES 3 4 SUBTOTAL 4 5 BLENDED CHARGE PROPORTION 5 6 COST OF OUTPATIENT RADIOLOGY 6 COMPUTATION OF LESSER OF COST OR CHARGES 7 TOTAL CHARGES 7 CUSTOMARY CHARGES 8 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES 8 ON A CHARGE BASIS 9 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICE 9 ON A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 10 RATIO OF LINE 8 TO LINE 9 10 11 TOTAL CUSTOMARY CHARGES 11 12 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 12 13 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 13 14 LESSER OF COST OR CHARGES 14 COMPUTATION OF REIMBURSEMENT SETTLEMENT 15 DEDUCTIBLES AND COINSURANCE 15 16 TOTAL 16 17 COST PROPORTION 17 18 OUTPATIENT RADIOLOGY BLENDED AMOUNT 18 19 LESSER OF LINE 16 OR LINE 18 19 20 PART B DEDUCTIBLES AND COINSURANCE 20 21 RADIOLOGY PAYMENT AMOUNT 21 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART E PART E - OTHER OUTPATIENT DIAGNOSTIC PROCEDURES [ ] TITLE V [XX] TITLE XVIII [ ] TITLE XIX HOSPITAL (15-0146) OCTOBER 1, 1997 PRIOR TO ON OR AFTER 1 1.01 1 PREVAILING CHARGES 1 2 42 PERCENT OF LINE 1 2 3 DEDUCTIBLES 3 4 SUBTOTAL 4 5 BLENDED CHARGE PROPORTION 5 6 COST OF OTHER OUTPATIENT DIAGNOSTIC PROCEDURES 6 COMPUTATION OF LESSER OF COST OR CHARGES 7 TOTAL CHARGES 7 CUSTOMARY CHARGES 8 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES 8 ON A CHARGE BASIS 9 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICE 9 ON A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 10 RATIO OF LINE 8 TO LINE 9 10 11 TOTAL CUSTOMARY CHARGES 11 12 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 12 13 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 13 14 LESSER OF COST OR CHARGES 14 COMPUTATION OF REIMBURSEMENT SETTLEMENT 15 DEDUCTIBLES AND COINSURANCE 15 16 TOTAL 16 17 COST PROPORTION 17 18 OTHER OUTPATIENT DIAGNOSTIC BLENDED AMOUNT 18 19 LESSER OF LINE 16 OR LINE 18 19 20 PART B DEDUCTIBLES AND COINSURANCE 20 21 DIAGNOSTIC PAYMENT AMOUNT 21 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/29/2009 10:18 ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED WORKSHEET E-1 HOSPITAL (15-0146) INPATIENT PART A PART B DESCRIPTION MM/DD/YYYY AMOUNT MM/DD/YYYY AMOUNT 1 2 3 4 1 TOTAL INTERIM PAYMENTS PAID TO PROVIDER 3850913 2629798 1 2 INTERIM PAYMENTS PAYABLE ON INDIVIDUAL BILLS EITHER NONE 51948 2 SUBMITTED OR TO BE SUBMITTED TO THE INTERMEDIARY FOR SERVICES RENDERED IN THE COST REPORTING PERIOD. IF NONE, WRITE 'NONE', OR ENTER A ZERO. 3 LIST SEPARATELY EACH RETROACTIVE LUMP SUM .01 3.01 ADJUSTMENT AMOUNT BASED ON SUBSEQUENT PROGRAM .02 3.02 REVISION OF THE INTERIM RATE FOR THE COST TO .03 NONE NONE 3.03 REPORTING PERIOD. ALSO SHOW DATE OF EACH PROVIDER .04 3.04 PAYMENT. IF NONE, WRITE 'NONE' OR ENTER A ZERO. .05 3.05 .50 3.50 PROVIDER .51 3.51 TO .52 NONE NONE 3.52 PROGRAM .53 3.53 .54 3.54 SUBTOTAL .99 3.99 4 TOTAL INTERIM PAYMENTS 3850913 2681746 4 TO BE COMPLETED BY INTERMEDIARY 5 LIST SEPARATELY EACH TENTATIVE SETTLEMENT PAY- PROGRAM .01 5.01 MENT AFTER DESK REVIEW. ALSO SHOW DATE OF EACH TO .02 NONE NONE 5.02 PAYMENT. IF NONE, WRITE 'NONE' OR ENTER A ZERO. PROVIDER .03 5.03 PROVIDER .50 5.50 TO .51 NONE NONE 5.51 PROGRAM .52 5.52 SUBTOTAL .99 5.99 6 DETERMINED NET SETTLEMENT AMOUNT PROGRAM TO (BALANCE DUE) BASED ON THE COST PROVIDER .01 192917 6.01 REPORT. PROVIDER TO .02 -273167 6.02 PROGRAM 7 TOTAL MEDICARE PROGRAM LIABILITY 4043830 2408579 7 NAME OF INTERMEDIARY: INTERMEDIARY NUMBER: _____________________________________________________ _____________ SIGNATURE OF AUTHORIZED PERSON: DATE (MO/DAY/YR): ___________________________________________ ________________ PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/1999) 05/29/2009 10:18 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E-3 PART III - TITLE V OR TITLE XIX SERVICES OR TITLE XVIII SNF PPS ONLY PART III [ ] TITLE V [ ] TITLE XVIII [XX] TITLE XIX HOSPITAL SUB I SUB II SUB III SUB IV NF I (15-0146) (PPS) COMPUTATION OF NET COST OF COVERED SERVICES 1 1 1 1 1 1 1 INPATIENT HOSPITAL/SNF/NF SERVICES 1 2 MEDICAL AND OTHER SERVICES 1139141 2 3 INTERNS AND RESIDENTS 3 4 ORGAN ACQUISITION CERTIFIED TRANSPLANT CENTERS O 4 5 COST OF TEACHING PHYSICIANS 5 6 SUBTOTAL 1139141 6 7 INPATIENT PRIMARY PAYER PAYMENTS 7 8 OUTPATIENT PRIMARY PAYER PAYMENTS 8 9 SUBTOTAL 1139141 9 COMPUTATION OF LESSER OF COST OR CHARGES 10 ROUTINE SERVICE CHARGES 10 11 ANCILLARY SERVICE CHARGES 4422073 11 12 INTERNS AND RESIDENTS SERVICE CHARGES 12 13 ORGAN ACQUISITION CHARGES, NET OF REVENUE 13 14 TEACHING PHYSICIANS 14 15 INCENTIVE FROM TARGET AMOUNT COMPUTATION 15 16 TOTAL REASONABLE CHARGES 4422073 16 CUSTOMARY CHARGES 17 AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE 17 18 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM 18 A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 19 RATIO OF LINE 17 TO LINE 18 19 20 TOTAL CUSTOMARY CHARGES 4422073 20 21 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 3282932 21 22 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 22 23 COST OF COVERED SERVICES 1139141 23 PROSPECTIVE PAYMENT AMOUNT 24 OTHER THAN OUTLIER PAYMENTS 24 25 OUTLIER PAYMENTS 25 26 PROGRAM CAPITAL PAYMENTS 26 27 CAPITAL EXCEPTION PAYMENTS 27 28 ROUTINE SERVICE OTHER PASS THROUGH COSTS 28 29 ANCILLARY SERVICE OTHER PASS THROUGH COSTS 29 30 SUBTOTAL 1139141 30 31 CUSTOMARY CHARGES (TITLE XIX PPS COVERED 31 32 LESSER OF LINES 30 OR 31 32 33 DEDUCTIBLES (EXCLUDE PROFESSIONAL COMPONENT) 33 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/1999) 05/29/2009 10:18 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E-3 PART III - TITLE V OR TITLE XIX SERVICES OR TITLE XVIII SNF PPS ONLY PART III [ ] TITLE V [ ] TITLE XVIII [XX] TITLE XIX HOSPITAL SUB I SUB II SUB III SUB IV NF I (15-0146) (PPS) 1 1 1 1 1 1 COMPUTATION OF REIMBURSEMENT SETTLEMENT 34 EXCESS OF REASONABLE COST 34 35 SUBTOTAL 35 36 COINSURANCE 36 37 SUM OF AMOUNTS FROM WKST E, PARTS C,D AND E, 37 38 REIMBURSABLE BAD DEBTS 38 38.01 REDUCED REIMBURSABLE BAD DEBTS 38.01 38.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE 38.02 BENEFICIARIES (SEE INSTRUCTIONS) 39 UTILIZATION REVIEW 39 40 SUBTOTAL 40 41 INPATIENT ROUTINE SERVICE COST 41 42 MEDICARE INPATIENT ROUTINE CHARGES 42 43 AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE 43 44 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM 44 A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 45 RATIO OF LINE 43 TO LINE 44 45 46 TOTAL CUSTOMARY CHARGES 46 47 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 47 48 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 48 49 RECOVERY OF EXCESS DEPRECIATION RESULTING FROM 49 UTILIZATION 50 OTHER ADJUSTMENTS 50 51 AMOUNTS APPLICABLE TO PRIOR COST REPORTING 51 DEPRECIABLE ASSETS 52 SUBTOTAL 52 53 INDIRECT MEDICAL EDUCATION ADJUSTMENT 53 54 DIRECT GRADUATE MEDICAL EDUCATION PAYMENTS 54 55 TOTAL AMOUNT PAYABLE TO THE PROVIDER 55 56 SEQUESTRATION ADJUSTMENT 56 57 INTERIM PAYMENTS 57 57.01 TENTATIVE SETTLEMENT (FOR FI USE ONLY) 57.01 58 BALANCE DUE PROVIDER/PROGRAM 58 59 PROTESTED AMOUNTS (NONALLOWABLE COST REPORT 59 SECTION 115.2 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 BALANCE SHEET WORKSHEET G ASSETS GENERAL SPECIFIC ENDOWMENT PLANT FUND PURPOSE FUND FUND FUND 1 2 3 4 CURRENT ASSETS 1 CASH ON HAND AND IN BANKS 10848 1 2 TEMPORARY INVESTMENTS 2 3 NOTES RECEIVABLE 3 4 ACCOUNTS RECEIVABLE 5131050 4 5 OTHER RECEIVABLES 545117 5 6 ALLOWANCE FOR UNCOLLECTIBLE NOTES & ACCOUNTS RECEIVABLE 6 7 INVENTORY 193557 7 8 PREPAID EXPENSES 120149 8 9 OTHER CURRENT ASSETS 9 10 DUE FROM OTHER FUNDS 10 11 TOTAL CURRENT ASSETS 6000721 11 FIXED ASSETS 12 LAND 12 12.01 ACCUMULATED DEPRECIATION 12.01 13 LAND IMPROVEMENTS 3489353 13 13.01 ACCUMULATED DEPRECIATION -1151656 13.01 14 BUILDINGS 18070468 14 14.01 ACCUMULATED DEPRECIATION -3226164 14.01 15 LEASEHOLD IMPROVEMENTS 1859 15 15.01 ACCUMULATED AMORTIZATION -901 15.01 16 FIXED EQUIPMENT 6104183 16 16.01 ACCUMULATED DEPRECIATION -1668230 16.01 17 AUTOMOBILES AND TRUCKS 99647 17 17.01 ACCUMULATED DEPRECIATION -64084 17.01 18 MAJOR MOVABLE EQUIPMENT 10795285 18 18.01 ACCUMULATED DEPRECIATION -6746233 18.01 19 MINOR EQUIPMENT DEPRECIABLE 19 19.01 ACCUMULATED DEPRECIATION 19.01 20 MINOR EQUIPMENT-NONDEPRECIABLE 20 21 TOTAL FIXED ASSETS 25703527 21 OTHER ASSETS 22 INVESTMENTS 22 23 DEPOSITS ON LEASES 23 24 DUE FROM OWNERS/OFFICERS 24 25 OTHER ASSETS 407070 25 26 TOTAL OTHER ASSETS 407070 26 27 TOTAL ASSETS 32111318 27 LIABILITIES AND FUND BALANCES GENERAL SPECIFIC ENDOWMENT PLANT FUND PURPOSE FUND FUND FUND 1 2 3 4 CURRENT LIABILITIES 28 ACCOUNTS PAYABLE 288603 28 29 SALARIES, WAGES & FEES PAYABLE 695467 29 30 PAYROLL TAXES PAYABLE 30 31 NOTES & LOANS PAYABLE (SHORT TERM) 16405 31 32 DEFERRED INCOME 32 33 ACCELERATED PAYMENTS 33 34 DUE TO OTHER FUNDS -1088738 34 35 OTHER CURRENT LIABILITIES 739719 35 36 TOTAL CURRENT LIABILITIES 651456 36 LONG-TERM LIABILITIES 37 MORTGAGE PAYABLE 37 38 NOTES PAYABLE 40420 38 39 UNSECURED LOANS 39 40 LOANS FROM OWNERS .01 PRIOR TO 7/1/66 40 .02 ON OR AFTER 7/1/66 41 OTHER LONG TERM LIABILITIES 6557 41 42 TOTAL LONG TERM LIABILITIES 46977 42 43 TOTAL LIABILITIES 698433 43 CAPITAL ACCOUNTS 44 GENERAL FUND BALANCE 31412885 44 45 SPECIFIC PURPOSE FUND BALANCE 45 46 DONOR CREATED-ENDOWMENT FUND BAL-RESTRICTED 46 47 DONOR CREATED-ENDOWMENT FUND BAL-UNRESTRICTED 47 48 GOVERNING BODY CREATED - ENDOWMENT FUND BAL 48 49 PLANT FUND BALANCE - INVESTED IN PLANT 49 50 PLANT FUND BALANCE - RESERVE FOR PLANT 50 IMPROVEMENT, REPLACEMENT AND EXPANSION 51 TOTAL FUND BALANCES 31412885 51 52 TOTAL LIABILITIES AND FUND BALANCES 32111318 52 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 STATEMENT OF CHANGES IN FUND BALANCES WORKSHEET G-1 GENERAL FUND SPECIFIC PURPOSE FUND ENDOWMENT FUND PLANT FUND 1 2 3 4 1 FUND BALANCES AT BEGINNING OF PERIOD 10306054 1 2 NET INCOME (LOSS) 6644830 2 3 TOTAL 16950884 3 4 ADDITIONS (CREDIT ADJUSTMENTS) 4 5 5 6 6 7 7 8 8 9 9 10 TOTAL ADDITIONS 10 11 SUBTOTAL 16950884 11 12 DEDUCTIONS (DEBIT ADJUSTMENTS) -14462001 12 13 ASSET TRANSFERS 13 14 14 15 15 16 16 17 17 18 TOTAL DEDUCTIONS -14462001 18 19 FUND BALANCE AT END OF PERIOD 31412885 19 PER BALANCE SHEET PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 STATEMENT OF PATIENT REVENUES AND OPERATING EXPENSES WORKSHEET G-2 PARTS I & II PART I - PATIENT REVENUES REVENUE CENTER INPATIENT OUTPATIENT TOTAL 1 2 3 GENERAL INPATIENT ROUTINE CARE SERVICES 1 HOSPITAL 7252560 7252560 1 2 SUBPROVIDER I 2 4 SWING BED - SNF 4 5 SWING BED - NF 5 6 SKILLED NURSING FACILITY 6 7 NURSING FACILITY 7 8 OTHER LONG TERM CARE 8 9 TOTAL GENERAL INPATIENT CARE SERVICES 7252560 7252560 9 INTENSIVE CARE TYPE INPATIENT HOSPITAL SERVICES 10 INTENSIVE CARE UNIT 10 11 CORONARY CARE UNIT 11 12 BURN INTENSIVE CARE UNIT 12 13 SURGICAL INTENSIVE CARE UNIT 13 14 OTHER SPECIAL CARE (SPECIFY) 14 15 TOTAL INTENSIVE CARE TYPE INPATIENT HOSPITAL SERVICE 15 16 TOTAL INPATIENT ROUTINE CARE SERVICES 7252560 7252560 16 17 ANCILLARY SERVICES 16857569 16857569 17 18 OUTPATIENT SERVICES 60400257 60400257 18 18.50 RHC 18.50 18.60 FQHC 18.60 19 HOME HEALTH AGENCY 19 20 AMBULANCE 4139672 4139672 20 21 CORF 21 22 ASC 22 23 HOSPICE 23 24 OCCUPATIONAL HEALTH 24 25 TOTAL PATIENT REVENUES 24110129 64539929 88650058 25 PART II - OPERATING EXPENSES 1 2 26 OPERATING EXPENSES 32441592 26 27 ADD (SPECIFY) 27 28 BAD DEBTS 3969077 28 29 29 30 30 31 31 32 32 33 TOTAL ADDITIONS 3969077 33 34 DEDUCT (SPECIFY) 34 35 35 36 36 37 37 38 38 39 TOTAL DEDUCTIONS 39 40 TOTAL OPERATING EXPENSES 36410669 40 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 STATEMENT OF REVENUES AND EXPENSES WORKSHEET G-3 DESCRIPTION 1 TOTAL PATIENT REVENUES 88650058 1 2 LESS - CONTRACTUAL ALLOWANCES AND DISCOUNTS ON PATIENTS' ACCOUNTS 46323716 2 3 NET PATIENT REVENUES 42326342 3 4 LESS - TOTAL OPERATING EXPENSES 36410669 4 5 NET INCOME FROM SERVICE TO PATIENTS 5915673 5 6 CONTRIBUTIONS, DONATIONS, BEQUESTS, ETC. 6 7 INCOME FROM INVESTMENTS 3817 7 8 REVENUE FROM TELEPHONE AND TELEGRAPH SERVICE 8 9 REVENUE FROM TELEVISION AND RADIO SERVICE 9 10 PURCHASE DISCOUNTS 10 11 REBATES AND REFUNDS OF EXPENSES 11 12 PARKING LOT RECEIPTS 12 13 REVENUE FROM LAUNDRY AND LINEN SERVICE 13 14 REVENUE FROM MEALS SOLD TO EMPLOYEES AND GUESTS 76938 14 15 REVENUE FROM RENTAL OF LIVING QUARTERS 15 16 REV FROM SALE OF MED & SURG SUPP TO OTHER THAN PATIENTS 767 16 17 REVENUE FROM SALE OF DRUGS TO OTHER THAN PATIENTS 217177 17 18 REVENUE FROM SALE OF MEDICAL RECORDS AND ABSTRACTS 18 19 TUITION (FEES, SALE OF TEXTBOOKS, UNIFORMS, ETC.) 19 20 REVENUE FROM GIFTS, FLOWER, COFFEE SHOPS, CANTEEN 20 21 RENTAL OF VENDING MACHINES 21 22 RENTAL OF HOSPITAL SPACE 53312 22 23 GOVERNMENTAL APPROPRIATIONS 23 24 GAIN/LOSS ON DISPOSAL OF ASSET -7248 24 24.01 MISC. COMMUNITY PROGRAMS 24.01 24.02 EMS SUBSIDY 283432 24.02 24.03 MISCELLANEOUS 100962 24.03 25 TOTAL OTHER INCOME 729157 25 26 TOTAL 6644830 26 27 27 28 28 29 29 30 TOTAL OTHER EXPENSES 30 31 NET INCOME (OR LOSS) FOR THE PERIOD 6644830 31 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:18 CALCULATION OF CAPITAL PAYMENT - TITLE XVIII - FULLY PROSPECTIVE METHOD WORKSHEET L HOSPITAL HOSPITAL SUB I SUB II SUB III (15-0146) (15-0146) 1 1.01 PART I - FULLY PROSPECTIVE METHOD 1 CAPITAL HOSPITAL SPECIFIC RATE PAYMENTS 1 CAPITAL FEDERAL AMOUNT 2 CAPITAL DRG OTHER THAN OUTLIER 322428 2 3 CAPITAL DRG OUTLIER PAYMENTS FOR SERVICES RENDERED 3 PRIOR TO OCTOBER 1, 1997 3.01 CAPITAL DRG OUTLIER PAYMENTS FOR SERVICES RENDERED 2194 3.01 ON OR AFTER OCTOBER 1, 1997 INDIRECT MEDICAL EDUCATION ADJUSTMENT 4 TOTAL INPAT DAYS DIVIDED BY NO OF DAYS IN CR PERIOD 4 [ E-3,PT VI,LN.18] [E,PT A,LN.3.17][x E-3,PT VI,LN.1] 4.01 NO. OF INTERNS & RESIDENTS 0.00 0.00 4.01 4.02 INDIRECT MEDICAL EDUCATION PERCENTAGE 4.02 4.03 INDIRECT MEDICAL EDUCATON ADJUSTMENT 4.03 DISPROPORTIONATE SHARE ADJUSTMENT 5 % OF SSI RECIPIENT PAT DAYS TO MEDICARE PART A PAT DAYS 5 5.01 % OF MEDICAID PAT DAYS TO TOTAL DAYS ON WKST S-3, PART I 5.01 5.02 SUM OF LINES 5 AND 5.01 5.02 5.03 ALLOWABLE DISPROPORTIONATE SHARE PERCENTAGE 5.03 5.04 DISPROPORTIONATE SHARE ADJUSTMENT 5.04 6 TOTAL PROSPECTIVE CAPITAL PAYMENTS 324622 6 PART II - HOLD HARMLESS METHOD 1 NEW CAPITAL 1 2 OLD CAPITAL 2 3 TOTAL CAPITAL 3 4 RATIO OF NEW CAPITAL TO TOTAL CAPITAL 4 5 TOTAL CAPITAL PAYMENTS UNDER 100% FEDERAL RATE 5 6 REDUCTION FACTOR FOR HOLD HARMLESS PAYMENT 6 7 REDUCED OLD CAPITAL AMOUNT 7 8 HOLD HARMLESS PAYMENT FOR NEW CAPITAL 8 9 SUBTOTAL 9 10 PAYMENT UNDER HOLD HARMLESS (GREATER OF LINE 5 OR LINE 9) 10 PART III - PAYMENT UNDER REASONABLE COST 1 PROGRAM INPATIENT ROUTINE CAPITAL COST 1 2 PROGRAM INPATIENT ANCILLARY CAPITAL COST 2 3 TOTAL INPATIENT PROGRAM CAPITAL 3 4 CAPITAL COST PAYMENT FACTOR 4 5 TOTAL INPATIENT PROGRAM CAPITAL COST 5 PART IV - COMPUTATION OF EXCEPTION PAYMENTS 1 PROGRAM INPATIENT CAPITAL COSTS 1 2 PROGRAM INPATIENT CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES 2 3 NET PROGRAM INPATIENT CAPITAL COSTS 3 4 APPLICABLE EXCEPTION PERCENTAGE 4 5 CAPITAL COST FOR COMPARISON TO PAYMENTS 5 6 PERCENTAGE ADJUSTMENT FOR EXTRAORDINARY CIRCUMSTANCES 6 7 ADJUSTMENT TO CAPITAL MINIMUM PAYMENT LEVEL FOR 7 EXTRAORDINARY CIRCUMSTANCES 8 CAPITAL MINIMUM PAYMENT LEVEL 8 9 CURRENT YEAR CAPITAL PAYMENTS 9 10 CURRENT YEAR COMPARISON OF CAPITAL MINIMUM PAYMENT LEVEL 10 TO CAPITAL PAYMENTS 11 CARRYOVER OF ACCUMULATED CAPITAL MINIMUM PAYMENT LEVEL 11 OVER CAPITAL PAYMENT 12 NET COMPARISON OF CAPITAL MINIMUM PYMNT LEVEL TO CAPITAL PYMNTS 12 13 CURRENT YEAR EXCEPTION PAYMENT 13 14 CARRYOVER OF ACCUMULATED CAPITAL MINIMUM PAYMENT LEVEL 14 OVER CAPITAL PAYMENT FOR FOLLOWING PERIOD 15 CURRENT YEAR ALLOWABLE OPERATING AND CAPITAL PAYMENT 15 (SEE INSTRUCTIONS) 16 CURRENT YEAR OPERATING AND CAPITAL COSTS (SEE INSTRUCTIONS) 16 17 CURRENT YEAR EXCEPTION OFFSET AMOUNT 17 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/29/2009 10:18 CALCULATION OF CAPITAL PAYMENT - TITLE XIX - COST METHOD WORKSHEET L HOSPITAL HOSPITAL SUB I SUB II SUB III (15-0146) (15-0146) 1 1.01 PART I - FULLY PROSPECTIVE METHOD 1 CAPITAL HOSPITAL SPECIFIC RATE PAYMENTS 1 CAPITAL FEDERAL AMOUNT 2 CAPITAL DRG OTHER THAN OUTLIER 2 3 CAPITAL DRG OUTLIER PAYMENTS FOR SERVICES RENDERED 3 PRIOR TO OCTOBER 1, 1997 3.01 CAPITAL DRG OUTLIER PAYMENTS FOR SERVICES RENDERED 3.01 ON OR AFTER OCTOBER 1, 1997 INDIRECT MEDICAL EDUCATION ADJUSTMENT 4 TOTAL INPAT DAYS DIVIDED BY NO OF DAYS IN CR PERIOD 4 4.01 NUMBER OF INTERNS AND RESIDENTS FROM WORKSHEET S-3, PART I 4.01 4.02 INDIRECT MEDICAL EDUCATION PERCENTAGE 4.02 4.03 INDIRECT MEDICAL EDUCATON ADJUSTMENT 4.03 DISPROPORTIONATE SHARE ADJUSTMENT 5 % OF SSI RECIPIENT PAT DAYS TO MEDICARE PART A PAT DAYS 5 5.01 % OF MEDICAID PAT DAYS TO TOTAL DAYS ON WKST S-3, PART I 5.01 5.02 SUM OF LINES 5 AND 5.01 5.02 5.03 ALLOWABLE DISPROPORTIONATE SHARE PERCENTAGE 5.03 5.04 DISPROPORTIONATE SHARE ADJUSTMENT 5.04 6 TOTAL PROSPECTIVE CAPITAL PAYMENTS 6 PART II - HOLD HARMLESS METHOD 1 NEW CAPITAL 1 2 OLD CAPITAL 2 3 TOTAL CAPITAL 3 4 RATIO OF NEW CAPITAL TO TOTAL CAPITAL 4 5 TOTAL CAPITAL PAYMENTS UNDER 100% FEDERAL RATE 5 6 REDUCTION FACTOR FOR HOLD HARMLESS PAYMENT 6 7 REDUCED OLD CAPITAL AMOUNT 7 8 HOLD HARMLESS PAYMENT FOR NEW CAPITAL 8 9 SUBTOTAL 9 10 PAYMENT UNDER HOLD HARMLESS (GREATER OF LINE 5 OR LINE 9) 10 PART III - PAYMENT UNDER REASONABLE COST 1 PROGRAM INPATIENT ROUTINE CAPITAL COST 1 2 PROGRAM INPATIENT ANCILLARY CAPITAL COST 2 3 TOTAL INPATIENT PROGRAM CAPITAL 3 4 CAPITAL COST PAYMENT FACTOR 4 5 TOTAL INPATIENT PROGRAM CAPITAL COST 5 PART IV - COMPUTATION OF EXCEPTION PAYMENTS 1 PROGRAM INPATIENT CAPITAL COSTS 1 2 PROGRAM INPATIENT CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES 2 3 NET PROGRAM INPATIENT CAPITAL COSTS 3 4 APPLICABLE EXCEPTION PERCENTAGE 4 5 CAPITAL COST FOR COMPARISON TO PAYMENTS 5 6 PERCENTAGE ADJUSTMENT FOR EXTRAORDINARY CIRCUMSTANCES 6 7 ADJUSTMENT TO CAPITAL MINIMUM PAYMENT LEVEL FOR 7 EXTRAORDINARY CIRCUMSTANCES 8 CAPITAL MINIMUM PAYMENT LEVEL 8 9 CURRENT YEAR CAPITAL PAYMENTS 9 10 CURRENT YEAR COMPARISON OF CAPITAL MINIMUM PAYMENT LEVEL 10 TO CAPITAL PAYMENTS 11 CARRYOVER OF ACCUMULATED CAPITAL MINIMUM PAYMENT LEVEL 11 OVER CAPITAL PAYMENT 12 NET COMPARISON OF CAPITAL MINIMUM PYMNT LEVEL TO CAPITAL PYMNTS 12 13 CURRENT YEAR EXCEPTION PAYMENT 13 14 CARRYOVER OF ACCUMULATED CAPITAL MINIMUM PAYMENT LEVEL 14 OVER CAPITAL PAYMENT FOR FOLLOWING PERIOD 15 CURRENT YEAR ALLOWABLE OPERATING AND CAPITAL PAYMENT 15 (SEE INSTRUCTIONS) 16 CURRENT YEAR OPERATING AND CAPITAL COSTS (SEE INSTRUCTIONS) 16 17 CURRENT YEAR EXCEPTION OFFSET AMOUNT 17 PROVIDER NO. 15-0146 COMMUNITY HOSPTAL OF NOBLE COU KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2009.01 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/29/2009 10:18 ALLOCATION OF ALLOWABLE CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES WORKSHEET L-1 PART I EXTRAORDI- I&R COST & COST CENTER DESCRIPTION NARY CAP- SUBTOTAL SUBTOTAL POST STEP- TOTAL REL COSTS DOWN ADJS 0 4A 25 26 27 GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 10 11 DIETARY 11 12 CAFETERIA 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 14 15 CENTRAL SERVICES & SUPPLY 15 16 PHARMACY 16 17 MEDICAL RECORDS & LIBRARY 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMED ED PRGM-(SPECIFY) 24 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 25 33 NURSERY 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 37 39 DELIVERY ROOM & LABOR ROOM 39 40 ANESTHESIOLOGY 40 41 RADIOLOGY-DIAGNOSTIC 41 41.01 CAT SCAN 41.01 44 LABORATORY 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA 47 49 RESPIRATORY THERAPY 49 50 PHYSICAL THERAPY 50 51 OCCUPATIONAL THERAPY 51 52 SPEECH PATHOLOGY 52 53 ELECTROCARDIOLOGY 53 53.01 NUTRITION SUPPORT 53.01 55 MEDICAL SUPPLIES CHARGED TO PAT 55 56 DRUGS CHARGED TO PATIENTS 56 OUTPATIENT SERVICE COST CENTERS 60 CLINIC 60 61 EMERGENCY 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 95 SUBTOTALS 95 NONREIMBURSABLE COST CENTERS 96 GIFT, FLOWER, COFFEE SHOP & CAN 96 98 PHYSICIANS' PRIVATE OFFICES 98 98.01 ROME CITY CLINIC 98.01 98.02 LIGONIER CLINIC 98.02 00 OCC. HEALTH 00 00.01 FOUNDATION 00.01 00.02 PHYSICIAN OFFICES 00.02 00.03 COMM HEALTH 00.03 00.04 VACANT SPACE 00.04 101 CROSS FOOT ADJUSTMENTS 101 102 NEGATIVE COST CENTER 102 103 TOTAL 103 104 TOTAL STATISTICAL BASIS 104 105 UNIT COST MULTIPLIER 105 105 UNIT COST MULTIPLIER 105 ***FINGERPRINT Line 1 N:lg2DnPbCAL5rbIHO.leq2nTbyXr0 ***FINGERPRINT Line 2 eIMIS0obf0FfdunvyUBWxot8d2xAp9 ***FINGERPRINT Line 3 lFYf7oymSI03F.4N