Please enter the number of operating Medicare beds at the facility at the end of this reporting period: xxxxxx Cost Report Related Questions: Yes No Description (if required) 1 Is this facility claiming any expenses allocated from a Management Company Report (HCF-3)? 2 Is this facility claiming any expenses from a Realty Company Report (HCF-2-NH)? 3 Does this report contain any accrued expenses which have been either unpaid or unfunded such as, for example, pension costs, workers' compensation, or any other self-insured expenses? If Yes, the unpaid or unfunded portions should be self-disallowed. 4 Does this report and claim for reimbursement include any amounts for services of non-paid workers as provided for in 101 CMR 206.00? If yes, provide a schedule of amounts and account numbers on the Footnotes and Explanations section and send a copy of the required agreement if not previously submitted. 5 Have you reported any individual's salary in more than one account, i.e., cost splitting? If so, explain on the Footnotes and Explanations section, giving method of allocation, amount and account numbers. 6 Have you reported any costs on this HCF-1 that come directly from the management company, in addition to what has been allocated through Schedule 10 of the HCF-3? If Yes, explain in detail in the Footnotes and Explanations section of this report giving the account(s) and the dollar amount(s) of the entry. 7 Except for accruals made pursuant to FASB-43, i.e. vacation and sick time earned but not yet paid, do all accruals represent expenses incurred only during the current reporting period? If No, provide details and explanations on the Footnotes and Explanations section. 8 Were there any additions or renovations subject to a Determination of Need? If so, please describe the project. 8a When were these assets placed into service? Was this project done in phases? If so, when are the expected dates of completion for the next phases?
8. If the facility is rented and an HCF-2-NH was filed, are the owners listed in question 7 related to any non-Massachusetts nursing homes or rest homes? Yes or No ____ If yes, please report facilities on Schedule 1 of HCF-2-NH. 9. If the facility is rented and an HCF-2-NH was filed, what is the reporting period of the HCF-2 realty company data? These dates should correspond to the HCF-2-NH cost report submitted to the Center. From: To: 10. Has the realty company changed ownership during the reporting period? YES ____ NO ____ If yes, please report the transaction date __________
PROPRIETORSHIP and PARTNERSHIP Balance: 12/31/2016 (from 2016 2500.0) 1 Other: Prior Period Adjustment(s) 2 Capital contribution during year HCF-1 Net income Drawing during year ( ) Balance: 12/31/2018 (2500.0) 3 CORPORATION Capital Stock Additional Paid-in Retained earnings Treasury Stock Total Balance: 12/31/2016 1 Other: Prior Period Adjustment(s) 2 of stock Additional paid-in capital HCF-1 Net income/(Loss) Dividends paid ( ) ( ) Treasury stock Purchased/Sold Balance: 12/31/2018 ( ) 3 (2620.0) (2630.0) (2650.0) (2640.0) (2500.0) 1 This amount should agree with acct. #2500.0, Total Net Worth on Schedule 9 of 2016 HCF-1. 2 Disclose all facts relative to adjustments(s) and explain on the Footnotes and Explanations page any impact on reimbursable costs as reported on prior year(s) cost report identifying the specific accounts affected. 3 This amount should agree with acct. #2500.0, Total Net Worth on Schedule 9 of 2018 HCF-1. Detail explanation for any difference.
Above charges related to unlicensed temporary nursing service agencies are disallowed and should also be entered in the non-allowable amount column for account 6042.2. NURSES AIDES PURCHASED SERVICE NURSING (6052.2) Name of Temporary Nursing Service Agency Department of Public Health Registration # Total Hours of Service (Round to one decimal place) Total Charges Total XXXXXXXXXX (6052.2) Above charges related to unlicensed temporary nursing service agencies are disallowed and should also be entered in the non-allowable amount column for account 6052.2.
Sole Proprietorship: Account #2530.01 Last Name _________________ % Time Devoted % Salary First Name _________________ Emp. Benefits Payroll Taxes Workers’ Comp. Title ______________________ Gr. Life/Hlth Ins. Draw $ Other: Total $ Partnership: Account #2540.01 # # # # Last Name _________________ % Time Devoted % % % % % Salary $ $ $ $ First Name__________________ Emp Benefits $ $ $ $ Payroll Taxes $ $ $ $ Workers’ Comp. $ $ $ $ Title Gr. Life/Hlth Ins. $ $ $ $ (Circle one) Draw $ $ $ $ $ Officer / Partner Other: $ $ $ $ Total $ $ $ $ $ Account #2540.01 # # # # Last Name _________________ % Time Devoted % % % % % Salary $ $ $ $ First Name _________________ Empl Benefits $ $ $ $ Payroll Taxes $ $ $ $ Workers’ Comp. $ $ $ $ Title Gr. Life/Hlth Ins. $ $ $ $ (Circle one) Draw $ $ $ $ $ Officer / Partner Other: $ $ $ $ Total $ $ $ $ $ 1Annual Draw or Earnings Distribution Corporation: Account # # # # # Last Name__________________ % Time Devoted % % % % % Salary $ $ $ $ $ First Name _________________ Emp Benefits $ $ $ $ $ Payroll Taxes $ $ $ $ $