Please enter the number of operating Medicare beds at the facility at the end of this xxxxxx reporting period: 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 If Yes, the unpaid or unfunded portions which have been either unpaid or unfunded should be self-disallowed. such as, for example, pension costs, workers' compensation, or any other self-insured expenses? 4 Does this report and claim for reimbursement If yes, provide a schedule of amounts include any amounts for services of non-paid and account numbers on the Footnotes workers as provided for in 101 CMR 206.00? and Explanations section and send a copy of the required agreement if not previously submitted. 5 Have you reported any individual's salary in If so, explain on the Footnotes and more than one account, i.e., cost splitting? Explanations section, giving method of allocation, amount and account numbers. 6 Have you reported any costs on this HCF-1 that If Yes, explain in detail in the Footnotes come directly from the management company, and Explanations section of this report in addition to what has been allocated through giving the account(s) and the dollar Schedule 10 of the HCF-3? amount(s) of the entry. 7 Except for accruals made pursuant to FASB-43, If No, provide details and explanations i.e. vacation and sick time earned but not yet on the Footnotes and Explanations paid, do all accruals represent expenses section. incurred only during the current reporting period? 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?
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?
hcf-1.docx