09-11,,,,,FORM CMS-1984-99,,,,,, 3890 (Cont.) COMPENSATION ANALYSIS SALARIES AND WAGES,,,,PROVIDER NO:,,PERIOD:,,,,, ,,,,,,FROM,,,,WORKSHEET A-1, ,,,,,,TO,,,,, ,,,,,,,,,,, ,COST CENTER DESCRIPTIONS,ADMINIS-,,SOCIAL,,,TOTAL,,,, ,(omit cents),TRATOR,DIRECTOR,SERVICES,SUPERVISORS,NURSES,THERAPISTS,AIDES,ALL OTHER,TOTAL (1), ,,1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 , ,GENERAL SERVICE COST CENTERS,,,,,,,,,, 1 ,Capital Related Costs-Bldg and Fixt.,,,,,,,,,,1 2 ,Capital Related Costs-Movable Equip.,,,,,,,,,,2 3 ,Plant Operation and Maintenance,,,,,,,,,,3 4 ,Transportation - Staff,,,,,,,,,,4 5 ,Volunteer Service Coordination,,,,,,,,,,5 6 ,Administrative and General,,,,,,,,,,6 ,INPATIENT CARE SERVICE,,,,,,,,,, 10 ,Inpatient - General Care,,,,,,,,,,10 11 ,Inpatient - Respite Care,,,,,,,,,,11 ,VISITING SERVICES,,,,,,,,,, 15 ,Physician Services,,,,,,,,,,15 16 ,Nursing Care,,,,,,,,,,16 16.20 ,Nursing Care -- Continuous Home Care,,,,,,,,,,16.20 17 ,Physical Therapy,,,,,,,,,,17 18 ,Occupational Therapy,,,,,,,,,,18 19 ,Speech/ Language Pathology,,,,,,,,,,19 20 ,Medical Social Services ,,,,,,,,,,20 21 ,Spiritual Counseling,,,,,,,,,,21 22 ,Dietary Counseling,,,,,,,,,,22 23 ,Counseling - Other,,,,,,,,,,23 24 ,Home Health Aide and Homemaker,,,,,,,,,,24 24.20 ,HH Aide & Homemaker -- Cont Home Care,,,,,,,,,,24.20 25 ,Other,,,,,,,,,,25 "(1) Transfer the amount in column 9 to Wkst A, column 1",,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, "FORM CMS-1984-99 (9/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3811)",,,,,,,,,,, ,,,,,,,,,,, Rev. 9,,,,,,,,,,,38-107 3890 (Cont.),,,,,FORM CMS-1984-99,,,,,,09-11 COMPENSATION ANALYSIS SALARIES AND WAGES,,,,PROVIDER NO:,,PERIOD:,,,,, ,,,,,,FROM,,,,WORKSHEET A-1, ,,,,,,TO,,,,, ,,,,,,,,,,, ,COST CENTER DESCRIPTIONS,ADMINIS-,,SOCIAL,,,TOTAL,,,, ,(omit cents),TRATOR,DIRECTOR,SERVICES,SUPERVISORS,NURSES,THERAPISTS,AIDES,ALL OTHER,TOTAL (1), ,,1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 , ,OTHER HOSPICE SERVICE COSTS,,,,,,,,,, 30 ,"Drugs, Biological and Infusion Therapy",,,,,,,,,,30 30.30 ,Analgesics,,,,,,,,,,30.30 30.31 ,Sedatives / Hypnotics,,,,,,,,,,30.31 30.32 ,Other -- Specify,,,,,,,,,,30.32 31 ,Durable Medical Equipment/Oxygen,,,,,,,,,,31 32 ,Patient Transportation,,,,,,,,,,32 33 ,Imaging Services,,,,,,,,,,33 34 ,Labs and Diagnostics,,,,,,,,,,34 35 ,Medical Supplies,,,,,,,,,,35 36 ,Outpatient Services (incl. E/R Dept.),,,,,,,,,,36 37 ,Radiation Therapy,,,,,,,,,,37 38 ,Chemotherapy,,,,,,,,,,38 39 ,Other,,,,,,,,,,39 ,HOSPICE NONREIMBURSABLE SERV.,,,,,,,,,, 50 ,Bereavement Program Costs,,,,,,,,,,50 51 ,Volunteer Program Costs,,,,,,,,,,51 52 ,Fundraising,,,,,,,,,,52 53 ,Other Program Costs,,,,,,,,,,53 100 ,Total,,,,,,,,,,100 "(1) Transfer the amount in column 9 to Wkst A, column 1",,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, ,,,,,,,,,,, "FORM CMS-1984-99 (9/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3811)",,,,,,,,,,, ,,,,,,,,,,, 38-108,,,,,,,,,,,Rev. 9