NURSING HOME COST REPORT UNDER TITLE XIX

GEORGIA DEPARTMENT OF COMMUNITY HEALTH

FOR HOSPITAL BASED NURSING FACILITES / ICF-MR PROVIDERS - STATE FACILITIES

PERIOD ENDED 6/30/2011

1. Medicaid Provider Number 2. Name of Facility 3. County

Select ID Select ID first. (This is an automatic field.)
Does Facility Name Agree
with Current NH License?

4. Legal Name of Facility 5. Telephone Number 6. County Code (see instructions)

7. Mailing Address 8. City 9. Zip Code

,GA

10. Facility E-mail Address 11. Facility E-mail Address Contact's Name

12. Administrator's Name 13. Administrator License Number 14. Federal Employer Identification No.

15. Skilled Georgia Permit Number(s) - 16. ICF - MR

17. Type of Facility Certified (Provide number of beds licensed for each type facility)

No. of Beds No. of Beds

(1) Entirely Nursing Facility
(NF) NF ICF-MR

(3) Distinct Parts

(2) Entirely Intermediate Care
Facility-Mental Retarded
(ICF-MR)

18. Change in Classification/Name

FROM TO EFFECTIVE DATE
Class:

Name:

19. For the cost centers for which the facility shared the cost of services with another service provider, enter the number of beds
involved in the appropriate column/s:

number routine and laund. hskpg., admin.

of beds special dietary op. and maint. and gen.

this facility

other provider/s

NOTE: If the costs of services are not shared with another provider, this facility cannot use this hospital based provider report to
fulfill its reporting requirements. (See instructions for definition.)

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 INDEX

Schedule Description Reference Page No.

Certification of Provider and Identification of Preparer CP 1

Occupancy and Rate Data A 2
Supplementary Statistical Information A-1 3
Statement of Operations B 4
Supporting Schedules to Statement of Operations - Revenues B-1 5
Calculations of Ancillary Cost Adjustments B-1A 6A
Supporting Schedules to Statement of Operations - Operating Expenses B-2 7
Supporting Schedules to Statement of Operations - Other Revenues and Non-Operating Expenses B-3 10
Adjustments to Expenses B-4 13

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 Provider No. Select ID
Provider Name: Select ID first. (This is an automatic field.) 6/30/2011
PREPARER IDENTIFICATION AND CERTIFICATION OF PROVIDER

SCHEDULE CP

IDENTIFICATION OF PREPARER IF OTHER THAN EMPLOYED BY PROVIDER

Signed:
Name of Individual Preparer Firm Name if Applicable

Date Mailing Address

Telephone Number City State Zip Code

CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER

MISREPRESENTATION OR FALSIFICATION
OF ANY INFORMATION CONTAINED IN THIS
COST REPORT MAY BE PUNISHABLE BY FINE
AND/OR IMPRISONMENT UNDER STATE OR FEDERAL LAW

I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying Cost Report, including the questionnaire and
supporting schedules, 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.

Name:

1. Owner 3. Administrator
2. Officer

Title

Date

PASSCODE:
DCH USE ONLY
(By entering the passcode which was sent to me by
DCH, I am signing this certification.)

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 CHECK FIGURES (NOTE: This analysis may produce a "NUMBERS DO NOT TIE!!!" ****If numbers do not tie, provide an
result, even if the numbers are essentially equal, because of rounding. If this is the case, simply note that
the numbers are materially equal in the explanation column.)
explanation here:

Sch. B-2, Line 40, Col. 6 -

1) Sch. B-4, Final Line, Col. 2 -
Variance

Sch. A, Line 13, Col. 8 -

2) Questionnaire, Page 1, Question 4 -

Sch. B-1, Line 14 -

3) Questionnaire, Page 1, Question 4 -

Please use macro button on Page i to verify that the name on your cost report
4) Has Provider Name been verified? - is correct.
 Provider No. Select ID
Provider Name: Select ID first. (This is an automatic field.) 6/30/2011
OCCUPANCY AND RATE DATA
SCHEDULE A

Part I - Inpatient Days

1 2 3 4 5 6 7 8 9
Medicare Private & Other Medicaid Medicaid Medicaid TOTAL TOTAL TOTALS
On-Site Hospital/ On-Site On-Site Hospital/
Leave (FFS) (CMO) Leave
On-Site Hospital/Leave NF ICF-MR NF ICF-MR NF ICF-MR On-Site Hospital/Leave TOTALS
1 July - - - - - - - - - - - -
2 August - - - - - - - - - - - -
3 September - - - - - - - - - - - -
4 October - - - - - - - - - - - -
5 November - - - - - - - - - - - -
6 December - - - - - - - - - - - -
7 January - - - - - - - - - - - -
8 February - - - - - - - - - - - -
9 March - - - - - - - - - - - -
10 April - - - - - - - - - - - -
11 May - - - - - - - - - - - -
12 June - - - - - - - - - - - -
13 TOTALS - - - - - - - - - - - -

PART II- Bed Capacity

NF ICF-MR TOTALS
1 Certified beds at beginning of period -
2 Certified beds at end of period -
3 Date(s) of change in number of certified beds, if applicable (month/day)
4 Bed days available during the period (See Instructions) -

Part III - Percent Occupancy

5 Total from line 13, Part I divided by line 4, Part II 0.0% 0.0% 0.0%

Part IV - Minimum Per Diem Semi-private Rates as of Last Day

of Reporting Period

6 Private Pay Patients

7 Medicare Patients
8 Medicaid Patients (FFS)
9 Medicaid Patients (CMO)
10 Other (Specify)
11
12

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 Provider No. Select ID
Provider Name:
Select ID first. (This is an automatic field.) 6/30/2011
SUPPLEMENTARY STATISTICAL INFORMATION
HOSPITAL BASED FACILITIES
SCHEDULE A-1

Bed Capacity

1 Certified beds at beginning of period

2 Certified beds at end of period

3 Date(s) of change in number of certified beds, if applicable (month/day)

4 Bed days available during the period (See Instructions)

5 Daily semi-private room rate for hospital medical/surgical bed as of last

date of reporting period.

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 Provider No. Select ID
6/30/2011
Provider Name: Select ID first. (This is an automatic field.)
STATEMENT OF OPERATIONS
PERIOD ENDED 6/30/2011
SCHEDULE B

1 2 3 4

Reference Per Books As Adjusted

(operating expenses
Per Medicare
Cost Report)

REVENUES: SCHEDULE B-1

1. Routine Services Line 14 -
2. Ancillary Services Line 28 -
3. Less - Allowances and
Adjustments Line 56 -
4. Net Revenues -

OPERATING EXPENSES: SCHEDULE B-2

5. Routine Services - NF Line 6 - -
6. Routine Services - ICF-MR Line 6
7. Special Services Line 11 - -
8. Dietary Line 15 - -
9. Laundry and
Housekeeping Line 19.b - -
10. Operation and Maintenance
of Plant Line 23.b - -
11. Administrative and
General Line 34 - -
12. Property and Related Line 39.b - -
13. Total Operating
Expenses Line 40 - -
14. Gross Profit (Loss)
from Operations
(Line 4 - Line 13) -

OTHER REVENUES AND

NON-OPERATING EXPENSES: SCHEDULE B-3
15. Other Revenues Line 41 -
16. Non-Operating Expenses Line 58 -
17. Net Income (Loss)
Before Income Taxes -
18. Provision for Income
Taxes
19. Net Income (Loss) -

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*(When filling out this electronic cost report, you may either manually key in amounts on each
schedule, or "map" these amounts using one of two mapping sheets. If you wish to use the
mapping feature, select an option below. Otherwise, ignore this page.)

There are two methods available to map your general ledger to the cost report….
With Option A, the account names associated with the Chart of Accounts numbers are included.
ex:
1 NF
2 Nursing Administration
3 Nursing School

With Option B, the account names are not included.

ex:
1
2
3

Please select one of these two options. You may change your selection at any time.
bers are included.
Mapping of Books to Cost Report
Provider Name: Select ID first. (This is an automatic field.)
Provider No. Select ID
FYE: 6/30/2011
Mapping of Books to Cost Report
Provider Name: Select ID first. (This is an automatic field.)
Provider No. Select ID
FYE: 6/30/2011
 Provider No. Select ID
Provider Name: Select ID first. (This is an automatic field.) 6/30/2011
SUPPORTING SCHEDULES TO STATEMENT OF OPERATIONS

REVENUES

SCHEDULE B-1

Account Balance
No. Per Books

300.00 ROUTINE SERVICE REVENUE

1. 300.11 NF - Private -
2. 300.12 NF - Medicare -
3. 300.13 NF - Medicaid -
4. 300.14 NF - Other Government -
5. 300.16 NF - Other -
6.

7. Subtotal -

8. 300.21 ICF-MR - Private -

9. 300.23 ICF-MR - Medicaid -
10. 300.24 ICF-MR - Other Government -
11. 300.26 ICF-MR - Other -
12.

13. Subtotal -

14. TOTAL ROUTINE SERVICE REVENUES(Line 7 plus Line 13) -

(Schedule B, Line 1)

Total Medicaid Medicare Private &

Charges Charges Charges Other
400.00 ANCILLARY SERVICE REVENUE (1) (2) (3) (4)

15. 401.00 Physician Care - - - -

16. 403.00 Pharmacy (Drugs) - - - -
17. 407.00 Oxygen (Resp. Therapy) - - - -
19. 412.00 Intravenous Therapy - - - -
21. -
22. -

23. 402.00 Physical Therapy - - - -

24. 404.00 Speech Therapy (Pathology) - - - -
25. 408.00 Occupational Therapy - - - -
26. 409.00 Medical Supplies & Equip - - - -
27. 414.00 Tube Feeding - - - -
28. 415.00 Radiology - - - -
29. 416.00 - - - -

30. TOTAL ANCILLARY SERVICE REVENUES - - - -

(SCHEDULE B,LINE 2)

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 Provider No. Select ID
Provider Name: Select ID first. (This is an automatic field.) 6/30/2011
SUPPORTING SCHEDULE TO STATEMENT OF OPERATIONS

REVENUES

SCHEDULE B-1

(Continued)

Account Balance
No. Per Books

500.00 -
599.00 ALLOWANCES AND ADJUSTMENTS TO REVENUES
31 500.10 Charity/Uncompensated Care - Nursing Facility -
32 500.20 Charity/Uncompensated Care - ICF-MR -
33 510.12 Contractual Allowance - NF - Medicare -
34 510.13 Contractual Allowance - NF - Medicaid -
35 510.14 Contractual Allowance - NF - Physician Care -
36 510.15 Contractual Allowance - NF - Physical Therapy -
37 510.16 Contractual Allowance - NF - Pharmacy (Drugs) -
38 510.17 Contractual Allowance - NF - Speech Therapy (Pathology) -
39 510.18 Contractual Allowance - Oxygen Therapy (Respiratory Therapy) -
40 510.19 Contractual Allowance - Recreational Activities (Therapy) -
41 510.20 Contractual Allowance - NF - Medical Supplies and Equipment Rental -
42 510.21 Contractual Allowance - NF - Other Special Services -
43 510.23 Contractual Allowance - ICF-MR - Medicaid -
44 510.24 Contractual Allowance - ICF-MR - Physician Care -
45 510.25 Contractual Allowance - ICF-MR - Physical Therapy -
46 510.26 Contractual Allowance - ICF-MR - Pharmacy (Drugs) -
47 510.27 Contractual Allowance - ICF-MR - Speech Therapy (Pathology) -
48 510.28 Contractual Allowance - ICF-MR - Oxygen Therapy (Respiratory Therapy) -
49 510.29 Contractual Allowance - ICF-MR - Recreational Activities (Therapy) -
50 510.30 Contractual Allowance - ICF-MR - Medical Supplies and Equipment Rental -
51 510.31 Contractual Allowance - ICF-MR - Other Special Services -
52 510.06 Contractual Allowance - Other -
53 520.00 Administrative, Courtesy and Policy Discounts & Adj. -
54 530.00 Provision for Doubtful Accounts -
55 540.00 Restricted Donations and Grants for Indigent Care -
56 550.00 Other -
57

58 TOTAL ALLOWANCES AND ADJUSTMENTS -

(Schedule B, Line 3)

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 Provider Name: Select ID first. (This is an automatic field.) Provider No. Select ID
SUPPORTING SCHEDULE TO STATEMENT OF OPERATIONS - OPERATING EXPENSES 6/30/2011
SCHEDULE B-2
1 2 3 4 5 6 7 8
Total NF or
ICF-MR Expense As Adjusted
Old New Net of Medicare NF or ICF-MR
Total NF or Capital Capital Depreciation Adjustments Cost Report Allowable
Description ICF-MR Amount Costs Costs Allocation to Expenses Adjustments Expenses
(From Medicare Worksheet A) (See From Medicare From Medicare (Add Columns (Schedule B-4) Column 5 plus/
Instructions) Worksheet B, Worksheet B, 2,3,and 4) minus 6 and 7)
Part II) Part III)
Routine Services:
1. NF or ICF-MR - - - -
2. Nursing Administration - - - -
3. Nursing School - - - -
4. Intern Resident Service - - - -
4a Employee Health & Welfare - - - -
5. - - - -
6. Total Expense - - - - - - -
(Schedule B, (Schedule B,
Special Services: Column 3, Line 5 or 6). Column 4, Line 5 or 6).
7. Social Services - - - -
8. Central Services - - - -
9. Pharmacy - - - -
10. Physician Care - - - -
10(a) Physical Therapy - - - -
(b) Speech Therapy - - - -
(c) Oxygen Therapy - - - -
(d) Occupational Therapy - - - -
(e) Other Medical Supplies - - - -
(f) Recreational Activities - - - -
(g) Intravenous Therapy - - - -
(h) Radiology - - - -
(i) Other Special Services - - - -
11. Total Expense - - - - - - -
(Schedule B, (Schedule B,
Dietary: Column 3, Line 7) Column 4, Line 7)
12(a) Dietary - - - -
(b) Supplemental Feeding - - - -
(c) Tube Feeding - - - -
13 Cafeteria - - - -
14 - - - -
15. Total Expense - - - - - - -
(Schedule B, (Schedule B,
Column 3, Line 8) Column 4, Line 8)

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 Provider Name: Select ID first. (This is an automatic field.) Provider No. Select ID
SUPPORTING SCHEDULE TO STATEMENT OF OPERATIONS - OPERATING EXPENSES 6/30/2011
SCHEDULE B-2
1 2 3 4 5 6 7 8
Total NF or
ICF-MR Expense As Adjusted
Old New Net of Medicare NF or ICF-MR
Total NF or Capital Capital Depreciation Adjustments Cost Report Allowable
Description ICF-MR Amount Costs Costs Allocation to Expenses Adjustments Expenses
(From Medicare Worksheet A) (See From Medicare From Medicare (Add Columns (Schedule B-4) Column 5 plus/
Instructions) Worksheet B, Worksheet B, 2,3,and 4) minus 6 and 7)
Part II) Part III)
Laundry and Housekeeping:
16. Laundry and Linen         ­            ­    -         ­   
17. Housekeeping         ­            ­    -         ­   
18.         ­            ­    -         ­   
19. Total Expense         ­           ­           ­            ­           ­           ­            ­   
19.a (Schedule B,
19.b Column 3, Line 9) Total L&H         ­   
(Schedule B,
Column 4, Line 9)
Operation and Maintenance of Plant:
20. Maintenance and Repairs         ­            ­    -         ­   
21. Operation of Plant         ­            ­    -         ­   
22.         ­            ­    -         ­   
23. Total Expense         ­           ­           ­            ­           ­           ­            ­   
23.a (Schedule B,
23.b Column 3, Line 10) Total O&M         ­   
(Schedule B,
Column 4, Line 10)
Administrative and General:
24. Data Processing         ­            ­    -         ­   
25. Purchasing         ­            ­    -         ­   
26. Admitting         ­            ­    -         ­   
27. Collections         ­            ­    -         ­   
28. Administration & General         ­            ­    -         ­   
29. Medical Records         ­            ­    -         ­   
30. Maintenance of Personnel         ­            ­    -         ­   
31. Nursing Aide Training/Testing         ­            ­    -         ­   
32. Provider Fee         ­            ­    -         ­   
33.         ­            ­    -         ­   
34. Total Expense         ­           ­           ­            ­           ­           ­            ­   
(Schedule B, (Schedule B,
Column 3, Line 11) Column 4, Line 11)

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 Provider Name: Select ID first. (This is an automatic field.) Provider No. Select ID
SUPPORTING SCHEDULE TO STATEMENT OF OPERATIONS - OPERATING EXPENSES 6/30/2011
SCHEDULE B-2
1 2 3 4 5 6 7 8
Total NF or
ICF-MR Expense As Adjusted
Old New Net of Medicare NF or ICF-MR
Total NF or Capital Capital Depreciation Adjustments Cost Report Allowable
Description ICF-MR Amount Costs Costs Allocation to Expenses Adjustments Expenses
(From Medicare Worksheet A) (See From Medicare From Medicare (Add Columns (Schedule B-4) Column 5 plus/
Instructions) Worksheet B, Worksheet B, 2,3,and 4) minus 6 and 7)
Part II) Part III)
Property and Related:
35. Depreciation Building - XXXX XXXX - - -
36. Depreciation Equipment - XXXX XXXX - - -
37. Property Costs
(See Instructions) XXXX - - - - -
38. - XXXX XXXX - - -
39. Total Expense (Schedule
Column 1, Line 12) - - - - - - -
39.a (Schedule B
39.b Column 3 Total P&R -
Line 12) (Schedule B
Column 4
40. Grand Total - - - - - - Line 12)
(Schedule B (Schedule B-4
Column 3, Line 13) Column 2, Line 79) -
DETAIL OF PROPERTY AND RELATED EXPENSES (Schedule B
SCHEDULE B-2A Column 4, Line 13)
1 2 3 4 5 6
Direct
Other Insurance Interest Depreciation Equipment Rental Total
1. Total Amount for Hospital
and Nursing Home -
2. Allocation Basis
3. Amount allocated to
Nursing Home - - - - - -
(Schedule B-2,
Column 5,
Line 39)

* Explain:

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 Provider No. Select ID
Provider Name: Select ID first. (This is an automatic field.) 6/30/2011
SUPPORTING SCHEDULES TO STATEMENT OF OPERATIONS
OTHER REVENUES AND NON-OPERATING EXPENSES

SCHEDULE B-3

Part I - Other Revenues

Account Balance Amount Offset

No. Per Books on Medicare A-8
OTHER OPERATING REVENUE
1. 465.00 Employee Housing - -
2. 466.00 Purchasing Services - -
3. 467.00 Parking - -
4. 468.00 Housekeeping Services - -
5. 469.00 Data Processing Services - -
6. 470.00 Sale of Abstracts/Medical Records - -
7. 471.00 Sale of Scrap and Waste - -
8. 472.00 Rebates and Refunds - -
9. 473.00 Vending Machine Commissions - -
10. 474.00 Other Commissions - -
11. 475.00 Employee and Guest Meals (Cafeteria Sales) - -
12. 478.00 Donated and Federal Surplus Commodities - -
13. 480.00 Television and Radio Rentals - -
14. 482.00 Laundry and Linen Services - -
15. 483.00 Telephone and Telegraph - -
16. 484.00 Activities Program (Social Services) - -
17. 491.00 Non-patient Room Rentals - -
18. 496.00 Management Service Fees - -
19. 497.00 Cash Discounts Earned on Purchases - -
20. 499.00 Other Operating Revenues (See Analysis Required Below) - -

21. TOTAL OTHER OPERATING REVENUES - -

ANALYSIS OF OTHER OPERATING REVENUE

(ACCOUNT NO. 499.00)

Description
22.
23.
24.
25.
26.
27.
28.

29. TOTAL (Must agree with total of Line 20) - -

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 Provider No. Select ID
Provider Name: Select ID first. (This is an automatic field.) 6/30/2011
SUPPORTING SCHEDULES TO STATEMENT OF OPERATIONS
OTHER REVENUES AND NON-OPERATING EXPENSES
SCHEDULE B-3
(Continued)

Account Balance Amount Offset

No. Per Books on Medicare A-8
NON-OPERATING REVENUES
30. 476.00 Grants, Endowments, and Trusts (Unrestricted Contributions) - -
31. 477.00 Donated Services - -
32. 481.00 Beauty and Barber Shop Revenue - -
33. 486.00 Personal Purchases - -
34. 487.00 Sales - Canteen and Gift Shop - -
35. 488.00 Uniform Sales - -
36. 490.00 Office and Other Rental Revenue - -
37. 492.00 Interest Income, Gains and Losses from Unrestricted Investments - -
38. 495.00 Gain or Loss on Sale of Assets - -
39. 498.00 Other Non-operating Revenue (See Analysis Required Below) - -
40. TOTAL NON-OPERATING REVENUES - -

41. TOTAL OTHER REVENUES (Total of Lines 21 and 40 must agree with
Schedule B, Line 15) - -

ANALYSIS OF OTHER NON-OPERATING REVENUE

(ACCOUNT NO. 498.00)
Description
42.
43.
44.
45.
46.
47.
48.

49. TOTAL (Must agree with total of Line 39) - -

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 Provider No. Select ID
Provider Name: Select ID first. (This is an automatic field.) 6/30/2011
SUPPORTING SCHEDULES TO STATEMENT OF OPERATIONS
OTHER REVENUES AND NON-OPERATING EXPENSES
SCHEDULE B-3
(Continued)

Part II - Non-Operating Revenues

Account Balance Amount Offset

No. Per Books on Medicare A-8

50. 960.00 Canteen and Gift Shop - -

51. 965.00 Rental (Sub-lease,etc.) - -
52. 970.00 Utilization Review Expense/Medical Care Review - -
53.
54.
55.
56.
57.
58. TOTAL NON-OPERATING EXPENSE (SCHEDULE B, LINE 16) - -

NURSE AIDE TRAINING AND TESTING COST SUMMARY

SCHEDULE B-3A

Account
No. Per Books
1 930.10 Salaries and Wages -
2 930.11 Employee Benefits & Payroll Taxes -
3 930.20 Supplies -
4 930.30 Travel -
5 930.40 Contracted Services -
6 930.50 Equipment -
7 930.90 Other Costs -
8 TOTAL NURSE AIDE TRAINING AND TESTING COSTS -
(Schedule B-2,
Line 31, Col 2)

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 Provider Name:
VENTILATOR SERVICES PROGRAM C
OTHER REVENUES AND NON-OPERAT

Direct and Indirect Ventilator Services Summary

Routine Services Special Services Dietary

DIRECT COSTS
Salaries & Wages
Benefits & PR Taxes
Contract Services
Supplies
Equipment
Other Costs
TOTAL DIRECT COSTS* - - -

INDIRECT COSTS
Vent Program Indirect Costs
(Schedule B-5)

TOTAL COSTS* - - -

* Adjustment should be made on Schedule B-2 to remove costs associated with the Ventilator Services Program.

Ventilator Services Patient Day Summary

Payor Source On-site Hospital/Leave Days Total Patient Days

Medicare -
Medicaid -
Other -
Total Ventilator Patient Days - - -

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 Provider No. Select ID
Select ID first. (This is an automatic field.) 6/30/2011
ILATOR SERVICES PROGRAM COST SUMMARY
R REVENUES AND NON-OPERATING EXPENSES
SCHEDULE B-3B

Laundry & Operations & Taxes &

Housekeeping* Maintenance* Property* Insurance* Total Costs

-
-
-
-
-
-
- - - - -

- - - - -

or Services Program.
 Provider No. Select ID
Provider Name: Select ID first. (This is an automatic field.) 6/30/2011
ADJUSTMENTS TO EXPENSES
SCHEDULE B-4

1 2 3 4
Schedule B-2
Line No. Clarifying Comments
Basis* Amount** (Instructions)
1. Television and telephone
2. Life Insurance premium
3. Sale of meals to other than patients
4. Vending machines
5.a Prescription drugs
5.b Non-Emergency Transportation
5.c Laboratory
6. Sale of drugs and supplies to other
than patients
7. Sale of scrap, waste, etc.
8. Purchase discounts
9. Rebates and refunds
10. Bad debts
11. Interest income on unrestricted
funds
12. Recovery of insured loss
13. Physician's medical services
14. Depreciation - non-patient care
15. Excessive depreciation
16. Excessive advertising
17. Gain or loss on sale of assets
18. Personal expenses-other
19. Cost of lodging rented or provided
owners/employees
20. Interest expense-nonpatient care
related
21. Related party-
22. Rent
23. Contracted Services
24. Allocated Expenses
25. Interest
26. Supplies
27. Depreciation
28. Tax penalties
29. Donations and contributions
30. Stock registration expense
31. Stockholder meetings
32. Excess directors' fees
33. Excess compensation
34. Franchise fees
35. Amortization of goodwill
 Provider No. Select ID
Provider Name: Select ID first. (This is an automatic field.) 6/30/2011
ADJUSTMENTS TO EXPENSES
SCHEDULE B-4
(continued)

1 2 3 4
Schedule B-2
Line No. Clarifying Comments
Basis* Amount** (Instructions)
36. Fund raising expenses
37. Disposal expenses of nonpatient
care assets
38. Nonreimbursable travel, including
convention and education
39. Sub-lease rental offset
40. Restricted grants and gifts offset
41. Nurse Aide Training and Testing -
43. Physical Therapy
44. Speech Therapy (Pathology)
45. Occupational Therapy
46.
47.
48.
49.

50. Medical Supplies

51. Radiology
52. Other Special Services
53.
54. Tube Feeding
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67. Total -

*The amounts entered should be noted "A" where the facility can determine costs. Where costs are not determinable, the notation
"B" should be entered to indicate that the amount receive for the service is the basis for the adjustment.
**Adjustments which will decrease per book expenses should be shown in parenthesis.

Additional Notes:

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 Provider No. Select ID
Provider Name: Select ID first. (This is an automatic field.) 6/30/2011

CAPITAL IMPROVEMENTS AFFECTING THE FAIR MARKET RENTAL VALUE RATE

SCHEDULE D-2

1. Did the Facility complete construction of

additional new beds during the cost report year? <--ANSWER

You answered yes above, please complete the following schedule:

If more than one addition was completed within a calendar year, please report the data for each addition separately.

Addition 1 Addition 2 Addition 3 Addition 4 Addition 5

Month and year of construction / / / / /
Number of beds added
Cost of the new construction

2. Did the Facility complete construction of

the replacement of beds during the cost report year? <--ANSWER

You answered yes above, please complete the following schedule:

The replacement of beds occurs when new construction is completed, however instead of increasing the number of licensed beds of a facility, a portion of the existing
licensed beds are relocated to the new construction.

Replacement 1 Replacement 2 Replacement 3 Replacement 4 Replacement 5

Month and year of construction / / / / /
Number of beds replaced
Cost of the new construction

3. Did the Facility complete construction of renovations

and/or major improvements during the cost report year? <--ANSWER

You answered yes above, please complete the following schedule:

Major renovation/replacement projects include those items capitalized as either land improvements, building, building improvements, leasehold improvements and equipment.
Do not include any costs associated with items listed in section 1 or 2 above (Addition or Replacement of New Beds).

Major renovation/replacement projects have a total cost equal to or greater than $500.00 per licensed bed at the time the project was completed. If a renovation/replacement
project involved construction activities in both the licensed nursing facility and the non-nursing sections of the facility, only those construction costs associated with the
licensed nursing facility section of the facility should be included. Documentation must be maintained to demonstrate how construction costs were allocated between NF
and non-NF.

Important: For the purposes of this report and the $500 per bed test, different projects can be combined. For example, if a roof was replaced, flooring was replaced, and
a new parking lot was paved in the same year, all these costs should be combined into a single total. If all the capital improvements made throughout the year are greater
than or equal to $500 per bed, then they should be included below as a renovation.

Renovation 1 Renovation 2 Renovation 3 Renovation 4 Renovation 5

Month and year of renovation / / / / /
Costs of renovations/major improvements
Additional square footage (if any)

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 Provider No.: Select ID
Provider Name: Select ID first. (This is an automatic field.)
NURSING HOME COST REPORT UNDER TITLE XIX
GEORGIA DEPARTMENT OF MEDICAL ASSISTANCE
HOSPITAL BASED NURSING FACILITIES / ICF-MR PROVIDERS - STATE FACILITIES

QUESTIONNAIRE AND CHECKLIST

PERIOD ENDED 6/30/2011
(To be filed with cost report.)

Note that an explanation must be provided for any "NO" answer-see space provided at the end of
the checklist. The designation N/A should be utilized if the question is not applicable.

Schedule A Yes No N/A

1. Inpatient days and occupancy data have

been accurately compiled from the census
records of the facility, and include hospital
and leave days that have been reimbursed
from any source.

2. The number of beds by type (NF and

ICF-MR) agrees with that certified by the
Licensure Unit of DHR.

3. Do the per diem rates in effect during the

year times the applicable patient days
total gross revenues reported on Schedule
B-1?

4. Complete the information listed below:

Applicable
Payor Period of Time Rate Patient Days Revenue

- -

(Schedule A, (Schedule B-1,

Column 9, Line 14)
Line 13)

NOTE: This information will be used to determine whether rates charged to Medicaid have ever
exceeded rates charged to any other payor.

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 Provider No.: Select ID
Provider Name: Select ID first. (This is an automatic field.) 6/30/2011

Schedule B-4 Yes No N/A

5. Per Federal Regulation 45CFR

441.13 (b), have all adjust-
ments related to federally
funded education programs,
such as Title I and Section V
been made?

General

6. Have two copies of the most

recently filed Medicare and/or
HCFP report, inlcuding all
schedules and attachments, been
submitted along with the
Hospital Based cost report?

7A. Self Insurance

Are you self-insured for any type

of coverage?

If yes, please answer parts A and B below.

A) What type of coverage is self-insured?

B) Are you claiming in allowable costs:

1. contributions to the fund?
2. actual claims paid out of the fund?

*If you chose both 1 and 2, explain here:

7B. Captive Insurance

Are you using a captive insurance Yes No

for any type of coverage?

If yes, what type of coverage is insured by the captive?

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 Provider No.: Select ID
Provider Name: Select ID first. (This is an automatic field.) 6/30/2011

COMMENTS ON "NO" ANSWERS (Except for question 7)

Question No. COMMENTS

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