Minnesota Department of Human Services
Instruction Manual
Annual Statistical and Cost Report
of Nursing Facilities
For the Reporting Year Ending September 30, 2015
This manual has been prepared to assist Providers participating in the Minnesota Medical Assistance Program in completing the annual statistical and cost report of nursing facilities.
WHAT’S NEW IN 2015 COST REPORTING?
Throughout this Manual and on the Cost Report form there have been changes made to some terminology to better align
with the terms used in Statute. These changes pertain to the use of “direct care.” These changes do not affect the
way that the Cost Report is completed, how rates are set, or how the measures for the Report Card are calculated.
To the extent possible, “direct care” has been replaced with “care related,” and the two types of “care related”
staff are defined in the following table. Both types of care related staff are included in the staff hours per
resident day and staff retention calculations used for the Minnesota Nursing Home Report Card.
| Care Related Type | Staff Categories Included | Purpose | Statutory Reference |
| Care related case-mix adjusted | Nursing Admin (6111), RN (6112), LPN (6113), C.N.A. (6114), TMA (6115) | calculate the direct care per diem in the operating rate | 256B.441, Subd. 11 |
| Care related other (NOT case-mix adjusted) | mental health workers (6118), Social Workers (6211), Activities (6212) and Other Care Related Staff (6213), and Salaries for Direct Care Staff Trainers (6260) | calculate the other care-related per diem of the operating rate | 256B.442, Subd. 28a and Subd. 48 |
The deadline for submission of the Annual Report is 11:59 pm on February 1, 2016.
The cost report must be filed electronically via the Provider Portal. Many of the reporting fields have been pre-filled based on information from your previous year cost report. After completion of your report, click on "Run the Edit Report." This edit report will contain messages that are either considered warnings or errors that must be corrected before the system will accept your report. Warnings will be messages where the data appears to be incorrect and you are asked to review the accuracy of the data. Other messages will identify required missing fields and other inconsistent data that doesn’t match throughout the report. These errors must be corrected before submitting the report.
You can exit the cost report and reenter the report at any time. Any data entered during a previous session will be saved if you have chosen to save changes. Once you have corrected all errors and clicked the submit button, you will not be able to retrieve the cost report. Print out a copy of the completed cost report for your records before the report is submitted. Please contact the Department if you have submitted an incorrect report. Contact information is provided below.
Any policy questions regarding the completion of the report which are not addressed in this manual should be directed to any of the following Department staff:
| Gloria Tiongson | gloria.tiongson@state.mn.us | 651-431-3746 |
| Gary M. Johnson | gary.m.johnson@state.mn.us | 651-431-2269 |
| Marilyn Kaufenberg | marilyn.kaufenberg@state.mn.us | 651-431-2270 |
| Kim Brenne | kimberly.brenne@state.mn.us | 651-431-4339 |
If you need technical assistance navigating the web-based application, please contact:
| Gary C. Johnson | gary.c.johnson@state.mn.us | 651-431-2279 |
If you are responsible for submitting multiple cost reports, there is an upload feature available which will allow you to upload a comma delimited text file which will pre-fill most of the line items in the cost report. After uploading, you will still need to review the cost report online, complete remaining fields such as reasons for adjustments to costs and revenues. The edit report must be reviewed and any corrections entered before submitting the final cost report.
Incomplete, Inaccurate or Late Reports:
The department may reject a report filed by a nursing facility if it is determined that the report has been
filed in a form that is incomplete or inaccurate and the information is insufficient to establish accurate
payment rates. If a report is rejected or is not submitted in a timely manner, the department will reduce
payments to a nursing facility to 85 percent of amounts due until the information is completely and accurately
filed. The reinstatement of withheld payments will be retroactive for no more than 90 days. A nursing facility
that does not file a report in a timely manner or whose report is rejected will be given written notice that a
payment reduction is to be implemented and allowed ten days to complete the report prior to any payment reduction.
A balance sheet and income statement corresponding to the reporting year are required to be filed with the cost report and may be submitted via email to the department at: DHS.NFRP.CostReport@state.mn.us or U. S. Mail to the following address:
Department of Human Services
Nursing Facility Rates & Policy
PO Box 64973
St. Paul, MN 55164-0973.
The department is allowed to require the filing of information to support the costs claimed under Minnesota Statutes, chapter 256B.441, subdivision 2. The required Supplemental Schedules described in “What’s New in 2015 Cost Reporting?” should also be sent to the same email and P O Box address above.
Administrator’s Certification:
This is a password protected site. The
administrator has been provided a unique user name and password. The password can be changed by the administrator
after the initial log in. The facility administrator is responsible for security of the password. If the
administrator provides the password to a staff person or other outside cost report preparer, they are
delegating the authority to those individuals to certify that the cost report submitted is a true and complete
statement prepared from the books and records of the nursing facility in accordance with applicable instructions.
Reporting Requirements:
The cost report contains 7 sections:
General Information, Beds, Resident Days, Employee Data,
Costs/Expenses, Assets/Debts/Leases, and Scholarship Expenses.
All seven sections
must be completed prior to submission. Moving between these sections
can be done by using your mouse to click on the titles listed on the left side of the screen.
All data in the Cost Report must be based on the reporting period ending September 30, 2015. Provide a reconciliation schedule between the working trial balance and the cost report. For a sample worksheet, see Supplemental Schedule F in the Facility Home Page of the NF Portal.
Facilities submitting a Medicaid nursing facility cost report must remove all costs associated with non-nursing facility operations using the adjustments column on the cost report. Column 3 on the costs/expenses section of the report must contain only nursing facility related costs. Costs which are separately reimbursed by residents, medical assistance, or other payors are to be removed using the Adjustments column. This includes costs incurred by providers in responding to a natural disaster as well as Ventilator-dependent Private Pay and MA recipients. If your organization has non-certified boarding care or other beds, you must remove the costs associated with these beds in the adjustments column.
Hospital-attached facilities are required to complete only the "Hospital-attached Expense Not Directly Identified" lines (the line numbers that end in "95") for all cost categories except as noted below. If the facility tracks direct expenses for some departments but not all, line item detail may be reported for those departments where expenses are directly identified. The amounts for the following lines (or other lines where expenses are directly identified) should be subtracted from the "Hospital-attached Expense Not Directly Identified" line in their corresponding category and reported on these individual lines:
| Line 7011 - Surcharge Expense |
| Line 7012 - Real Estate Taxes |
| Line 7014 - Special Assessments |
| Line 7015 - MDH Nursing Facility License |
| Line 7017 – Scholarship Costs |
| Line 7018 – PERA Contributions |
| Line 7020 – Resident & Family Advisory Council Costs |
| Line 9021 – Health Savings Account (HSA) |
| Line 9022 – Group Medical Insurance |
| Lines 6111 through 6290 – Care Related Costs |
Hospital-attached facilities are allowed to use the same step-down statistics as their Medicare fiscal year end. However, report year end costs at 9/30/15 are to be used for the step-down.
"Explanations of Adjustments Made to the Report" are to be entered if adjustments are made to any item on the Cost Report. If you enter an amount into the adjustments column, an icon will appear. Click the icon to open a box to give an explanation for the adjustment. The drop down menu has a list of common adjustment explanations to choose from. If the drop down menu does not contain the explanation that you need you must enter your explanation of the adjustment in this box. As you proceed through the cost report, the drop down menu will save each explanation you have entered. If you have multiple adjustments with the same explanation, simply click on the explanation already displayed on the drop down menu that applies.
Note that only one adjustment explanation can be entered per cost report line. DHS audit adjustment explanation will supersede a prior adjustment explanation entered. If you have multiple adjustments and/or several explanations for one cost report line, submit an explanation of adjustments worksheet. For a sample worksheet, see Supplemental Schedule G in the Facility Home page of the NF Provider Portal.
Unless otherwise indicated, all numeric data must be rounded to the nearest whole number (i.e., round .4 down, round .5 up).
The following information pertains to specific sections and/or lines of the Cost Report.
Please review each of the data fields carefully and complete or change them as needed. Click on the nearest Save Current Work button to update the general information page.
General and Ownership InformationFacility Licensed Name: Record the licensed name as it appears on the license granted by the Department of Health. If the licensed name is longer than 75 characters, abbreviate as necessary.
Ownership Code (Type): An organization is considered to have control if it has the power, directly or indirectly, to direct or to influence significantly the actions or policies of another organization or institution.
Physical Plant Owner: The physical plant owner field must have a valid selection. Use the drop-down menu to select the type of entity that owned the physical building of the nursing facility on the last day of this cost reporting period. This may or may not be different than the ownership code. Note that Real Estate Investment Trust (REIT) is included in the drop-down menu.
Admissions during report year: Record the total number of NF and NFII resident admissions (Medicaid and non-Medicaid).
Legal Business Name as reported to the Internal Revenue Service (IRS): Record the name of the parent or controlling organization as it appears in the records of the IRS. If the name is longer than 40 characters, abbreviate as necessary.
Controlling Organization: Record the name of the parent or controlling organization as it appears in the records of the Minnesota Secretary of State offices or in the Secretary of State offices of the state where the parent/controlling organization was formed. If the name is longer than 40 characters, abbreviate as necessary. An organization is considered to have control if it has the power, directly or indirectly, to influence or direct significantly the actions or policies of another organization or institution.
Number of facilities: The Minnesota facilities line must be at least "1" (for this facility).
Beds Data| Report the amount(s) currently charged for a single-bed room (a.k.a., the private room differential). |
| 5001 - 5050 |
Total Nursing Home resident days must be broken down into the 50 categories under the
MINNESOTA Case Mix Classification RUGS-IV System for dates of service October 1, 2014 through
September 30, 2015. Record the RUG determination made by the
Department of Health to classify each
of the residents. The total days must be broken down to the proper column (Private Pay,
Medicaid, Medicare, Other). Medicaid resident days will be the actual days of care for which
Medicaid made payments to the nursing facility and can be verified
on a MN Medicaid Remit. List nursing home residents only (NF Rule 80
and NF non-Rule 80) on these lines. Do NOT include resident
days provided in nursing home beds that are not certified as NF in the Medicaid program.
Do not report negative patient days in any field. Examples of "Other" days include Veterans
Administration, Railroad, HMO, LTC Insurance, and Managed Care Health Plans (i.e., MSHO, MSC+).
Hospice days should be reported by whichever
payor was reimbursing the nursing home for room and board, typically either Private Pay or
"Other." For example, if a hospice agency is paying the nursing home for room and board, the
days should be reported as "Other" days regardless of who is paying the hospice agency. Unpaid
bedhold days are not to be included in the report. |
| 5051 - 5100 |
NF II residents
are to be listed on these lines. Do NOT include resident days provided in Board and Care
licensed beds that are not certified as NFII. |
|
NOTE: If the facility had resident days at a penalty classification, these days are to be
reported as resident days at the RUG class established immediately after the penalty period,
if available, and otherwise, at the RUG class in effect just prior to when the penalty period
began. |
| 1619 - 1638 |
In column 1, record the number of employees on October 1, 2014. Include a part-time
employee as one employee, not as a fraction of a full-time employee. Employees shared between
two facilities under the same ownership or management should be counted as an employee for both
of the facilities. |
|
Van drivers/Transportation
staff is to be included as a care related worker if they
are nursing, social service or activities staff and should be reported in those
categories. A full time van driver or an employee of a support service category
such as maintenance should not be included in the care related employee data.
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A seasonal employee should be counted as an active employee if they are working
at the end of the reporting period or it is anticipated they will be working in the
next 10 months or 300 days.
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On-call employees:
On-call employees are not to be included in the employee data. An
on-call employee provides temporary services for the nursing facility and the nursing
facility includes the employee on their payroll system. An on-call employee is not regularly
scheduled at any time during the reporting period. A regularly scheduled part or full-time
employee that changed to on-call status during this reporting period is to be counted as a termination.
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Probationary employees :
Employees are considered active employees on their hire date. Employees
still in their probationary period at the beginning of the report are included in
the number of employees reported at the beginning of the report year.
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|
| 1619 - 1638 |
In column 2,
record the number of employees who were employed for the entire reporting year
for each job category. In other words, of those listed in column 1, report how many were
still employed on the last day of this reporting year. In column 2, do not include employees who
transferred from listed categories to job categories other than those listed. Do include
employees that transfer within these job categories. An employee transferring to another
job category listed and still employed at the end of the report year, should be counted
in the category where they started the report year.
|
| 1619 |
Nursing administration includes licensed nursing staff responsible for management of
the nursing department or primarily responsible for record keeping. Examples of nursing
administration staff include: DON, ADON, MDS coordinator, Medicare nurse, in-service
educator, infection control nurses and quality coordinators. Staff performing administrative
duties that are not licensed as a nurse, such as a unit coordinator, scheduler or medical
records staff are not to be counted as care related nursing administration staff.
|
| 1637 |
Activities staff includes volunteer coordinators and beauty shop staff.
|
| 1638 |
Other Care Related Staff means any other staff providing care related services to residents including;
feeding assistants and religious personnel. Room service attendants are not considered care related
staff. Dietary aides who are not trained and certified as feeding assistants should not be included.
Volunteer coordinators should be reported on line 1637. Do not include licensed therapists or assistant
therapists working under a licensed therapist’s supervision performing billable therapy services.
Generally, for retention reporting purposes, employees should be classified according to their
certification or licensure category regardless
of the job title. Universal workers who are C.N.A.s should be reported on the C.N.A. line.
|
Care Related Staff Retention Rate is determined by the number of care related employees on October 1, 2014 that were still employed on September 30, 2015 divided by the number of care related employees on October 1, 2014.
Productive Hours|
0301 - 0325 |
Generally, all hours worked by employees classified as care related workers
are to be reported as productive hours, including licensed nursing administrative staff.
This includes on-the-job training for both the trainee and the trainer. Employees performing both
care related and support services must have their hours and wages allocated between cost categories. The
allocation methodology must be documented by the facility and be available upon request by the Department.
Care related hours worked by Universal workers who are C.N.A.s should be allocated to the C.N.A. line. The
proportion of hours related to non-care related duties such as housekeeping or dietary, are not to be included
as productive care related hours. Periodic time studies, in lieu of ongoing time reports, may be used to
allocate direct salary and wage costs between applicable cost categories. A sample Universal Worker Time Study
Template is on the Facility Home page of the NF Provider Portal. The time studies must meet the
following criteria:
|
| The following exceptions are not to be reported as productive hours: | |
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Pool Usage Calculation: The Temporary Staff Pool Usage Percentage is calculated by using the total Nursing Pool RN, LPN, C.N.A., TMA hours divided by the total RN, LPN, C.N.A., TMA productive hours and total Nursing Pool RN, LPN, C.N.A., and TMA hours.
Care Related Staff Hours per Resident Day: The following list describes the steps taken to determine the care related staff hours per resident day.
|
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Indicate whether the nursing facility offered employee health insurance during the cost report period. If yes, enter the number of
employees enrolled in the employee health insurance as of the last day of the report period. |
| Line(s) | Remarks |
| General |
"Balance per Books" must be recorded using the following principles:
|
| General |
Costs reported on the report must use the Medicare cost reporting
principles. These principles adjust facility balance per books costs to actual cost and do not allow
costs that are not directly related to the care of residents to be claimed for computation of a
reimbursement rate. The Adjustments column is to be used to:
|
| General |
"Bonuses" are to be recorded in applicable salary lines. |
| General |
"Changes in Accrued Vacation/Sick Leave Pay" is the change in amount not utilized
by the employee from year to year. It is computed by taking the accrued vacation pay and sick leave balances
at the end of the reporting year and deducting the accrued vacation pay and sick leave balance at the end of
the prior reporting year. Scroll to the attachments section of this manual for an example. Changes in accrued
pay cannot be reported in salaries lines (line 6113, 6313, or 8013, for example). Changes in accrued pay must
be reported in the cost report lines that end with "17". Click here to see a sample calculation. |
| General |
Costs of functions normally paid by charges to residents, employees,
visitors, or others such as the direct and indirect costs of operating a pharmacy, congregate dining
program, home delivered meals program, gift shop, coffee shop, apartments or day care center are
non-allowable. |
| General |
"Applicable Credits" must be used to offset or reduce the expenses of the
nursing facility to the extent that the cost to which the credits apply was claimed as a nursing
facility cost. The gross amount of the credit must be recorded on the "Applicable Credits" line. The
related expenses must be reported on the appropriate expense line. Costs associated with expenses not
related to resident care may be adjusted on the applicable expense line or total revenue associated with
income not related to the nursing facility may be reported as an applicable credit. Do not net the
income and expense on one line. |
| General |
"Explanations of Adjustments Made to the Report" are to be entered if
adjustments are made to any item on the Cost Report. If you enter an amount into the adjustments column,
a drop down menu will automatically appear. You must enter your explanation of the adjustment in this box.
As you proceed through the cost report, the drop down menu will save each explanation you have entered.
If you have multiple adjustments with the same explanation, simply click on the explanation already
displayed on the drop down menu that applies. Note that only one adjustment explanation can be entered per cost report line. DHS audit adjustment explanation will supersede a prior adjustment explanation entered. If you have multiple adjustments and/or several explanations for one cost report line, submit an explanation of adjustments worksheet. For a sample worksheet, see Supplemental Schedule G in the Facility Home page of the NF Provider Portal. |
| General |
If you are not a hospital-attached facility, all lines ending in "95" should
be left blank, for example 6495. |
| General | Personnel with multiple duties: When a person other than top management personnel has multiple duties, the person's salary cost must be allocated to the cost categories on the basis of time distribution records that show actual time spent, or an accurate estimate of time spent on various activities. In a nursing facility of 60 or fewer beds, part of the salary or salaries of top management personnel may be allocated to other cost categories to the extent justified in time distribution records which show the actual time spent, or an accurate estimate of time spent on various activities. A nursing facility that chooses to estimate time spent must use a statistically valid method. Persons who serve in a dual capacity, including those who have only nominal top management responsibilities, shall directly identify their salaries to the appropriate cost categories. The salary of any person having more than nominal top management responsibilities must not be allocated. |
| General | For each salary line, click the “Yes” button if there is a union agreement in place effective on the last day of the reporting year. From the drop-down box, select the bargaining unit that covers the employees whose salaries are reported on that line. This cannot be done until the General Information section is completed. |
| 6111 |
Nursing administration includes licensed nursing staff responsible for
management of the nursing department or primarily responsible for record keeping. Examples of nursing
administration staff include: DON, ADON, MDS coordinator, Medicare nurse, infection
control nurses and quality coordinators. Staff in this category are primarily performing job duties where
a nursing license is required. |
| 6116 |
Medical Records staff that are primarily responsible for
record keeping or other administrative duties within the nursing department are to be reported on this
line. Examples include unit coordinators, schedulers, medical records staff; duties for which a nursing
license is not required, etc. Please note the difference between line 6111 and line 6116 with
regards to licensure. |
| 6212 |
Activities staff includes volunteer coordinators and beauty shop staff. |
| 6213 |
Other Care Related Staff includes staff providing care related services to residents
who are not appropriately categorized on lines 6111 through 6212. Generally, employee salaries should be
classified according to their certification or licensure category regardless of their job title. Examples
of Other Care Related Staff include feeding assistants, religious personnel, and non-licensed and non-certified
therapy aides. Other Care Related Staff does not include licensed therapists or therapy assistants providing
services for billable therapies, including Medicare Part A and B. |
| 6260 |
Record the wages of the employee in charge of conducting training in resident care
topics for care related staff. Typically this will be the in-service director. Effective July 1, 2015, the
employee scholarship program will provide reimbursement for nursing assistant training for newly hired and
recently graduated nurse aides. If facility staff provides the nursing assistant training, the wages associated
with the time spent conducting this training and competency evaluation, on and after July 1, 2015, may be
classified as scholarship costs on line 7017 instead of line 6260. |
| 6261 |
Report non-wage related costs of training care related staff on this line. Costs incurred on and after July 1, 2015
that pertain to the training expenses for nursing assistants may be reported on line 7017 (scholarship costs) instead
of line 6261. Individual scholarship records will need to be completed for any costs reported on line 7017. |
| 6140 |
All prescription drugs paid for by the facility are to be recorded on this
line. Pharmacy expenses are not an allowable cost as they are reimbursed by other payor sources. The
nursing facility related costs column will typically be zero. |
| 6220 |
"Activity and Social Service Supplies" include beauty shop supplies,
television and radio in common areas and pet supplies. |
| 6176 |
"Health Care Consultants" includes utilization review, pharmacy, in-service,
medical records, physician fees, nursing, infection control, medical director, other consultants and
physical, occupational, speech and mental health consultants, and interim nursing
administration. Therapy consultants doing nurse's
in-service training may be reported on this line. Consulting fees for therapy shall only be reported
as nursing facility related costs to the extent that the nursing facility or the nursing facility's
contractor does not bill separately for these services. |
| 6179 |
"Other Care Related Consultants" include social services, activities and
religious consulting. |
| 6240 |
All therapy salaries are reported on this line. Therapy salaries include
licensed therapists and assistant therapists working under their supervision performing billable therapy,
including Medicare Part A and B or any other third party payor. Therapists and therapy aides employed by
the facility that are not providing billable services should also be reported here. Costs associated with
billable services should be removed in the adjustment column. |
| 6274 |
Facilities which
bill separately for therapy services or whose contractor bills separately for therapy services shall remove
the costs of those services in the "adjustments" column. Payments to therapists who are
not employees of the nursing facility are reported here. |
| 6280 |
All other care related expenses not reported above, including non-therapy and non-pharmacy ancillaries
are to be reported here. Any of these expenses that are separately reimbursed (e.g., Medicare lab,
x-ray, and billable medical supplies)
must be removed in the adjustment column of this line. Provide a detailed schedule for the amount reported on this line. The detailed schedule should include the date, amount paid, vendor name, and the description/type of expenditure. Please see Supplemental Schedule C for a sample schedule. |
| 6290 |
Beauty shop rental income is reported here. Provide a detailed schedule for the amount reported on this line. The detailed schedule should include the date, amount received, vendor name, and the description/type of revenue. Please see Supplemental Schedule D for a sample schedule. |
| General |
The salary expense of the Environmental Supervisor working in more than
one department should be allocated between cost categories. |
| 6313 |
"Dietary salaries" include the director, dietician, other dietary salaries
and bonuses. |
| 6330 |
Raw food costs means the cost of food provided to nursing facility
residents. This includes special dietary supplements used for tube feeding or oral feeding, such
as elemental high nitrogen diet. Hospital-attached facilities must break this expense
out from line 6395 or the Provider Portal system edits will prohibit the cost report
from being submitted. |
| 6380 |
Other dietary expenses include contracted food service (excluding food),
supplies, and dietician consulting fees. Dietary training and travel is to be reported on line 8080. |
| 6390 |
Adjustments should be made to remove the costs of providing day care meals,
meals on wheels or other meals not related to resident care and the associated revenue from the cost
report. Costs associated with meals not related to resident care may be adjusted on the applicable
expense line or total revenue associated with meal income may be reported as an applicable credit. Enter the number of meals served and the associated revenue in Supplemental Schedule A, also labeled “Insurance & Meals Served”. |
| 6413 |
Laundry salaries include the department head, other laundry and linen
personnel and bonuses. |
| 6480 |
Other laundry and linen include supplies, linen and bedding and purchased
laundry services. |
| 6513 |
Housekeeping salaries include housekeeping director, other housekeeping
personnel and bonuses. |
| 6580 |
Other housekeeping includes supplies and contracted housekeeping. |
| 6613 |
Plant operations salaries include the maintenance chief, other maintenance
personnel and bonuses. |
| 6630 |
Utilities include fuel, electricity, water, and sewer. |
| 6680 |
Other maintenance expenses include supplies, repair parts, minor equipment,
maintenance and service contracts, purchased services and medical waste and garbage removal. Licenses
and permits are to be recorded in the general and administrative cost category on line 8080. MDH License
fees are recorded on line 7015, External Fixed. All minor equipment which is not required to be capitalized must be reported here. Examples of minor equipment are bedpans, kitchen utensils, cleaning utensils, and waste baskets. Minor equipment that must be capitalized per Generally Accepted Accounting Principles (GAAP) should be reported on line 1366, Assets Section. |
| 9011- 9026 |
This section of the cost report must be completed with the exception
of line 9017. Changes in Accrued Vacation/Sick Leave Pay may be reported in each individual cost
category on the lines ending with "17" for all employees in the nursing facility. The information on
lines 9100 to 9280 may be completed in addition to this section to directly allocate the costs by
cost category. Central office fringe benefits cannot be included on this page. Adjustments to offset payroll taxes and fringe benefits allocated to non-reimbursable areas or other operations should be made to the appropriate payroll tax or benefit line. |
| 9023 |
“Other Employee Insurance” includes disability insurance and group life insurance.
|
| 9025 |
Report the employer portion of the dental insurance expense for the reporting period.
|
| 9080 | "Other Employee Benefits" includes day care, employee physicals, flu shots, and in-kind benefits. Expenses reported here must not be reported on lines 9210 to 9280. |
| 9110 - 9200 |
These lines are optional and should be completed only if you choose to
directly identify payroll taxes and fringe benefits to each cost category. However, if the fringe
benefits and payroll taxes reported on lines 9011 through 9026 cannot all be directly identified --
leave lines 9110-9200 blank -- and the costs will be allocated based on a ratio of salary costs. |
| 7012 |
Only amounts paid for real estate taxes should be reported on this line. Use the adjustment column
to reduce the tax for all non-nursing home square footage.
Special assessments paid during the reporting year should be reported on line 7014. Nonprofit
organizations making payments in lieu of real estate taxes must document the amount claimed on line
7012. This documentation must be available if requested by the Department. The amounts for fire, police,
sanitation, and road maintenance services may be claimed.
Click here for a sample calculation. |
| 7014 |
Special assessments paid during the reporting year should be reported on
this line. Use the adjustment column to reduce the special assessments for all non-nursing home square footage.
Special assessments must not be included with real estate taxes on line 7012. |
| 7015 |
The Department of Health nursing facility license cost must be reported on this
line. All other license costs, including the administrator's license, should be reported on line 8080. |
| 7017 |
ONLY the allowable expenses related to the scholarship program created in Minnesota
Statutes 256B.431, subdivision 36, should be included in the Nursing Facility Related Costs column of this line.
These expenses are limited to amounts related to tuition and direct educational expenses. Tuition, mandatory fees,
and required books and supplies are considered direct educational expenses, thus allowable. The following expenses incurred
on or after July 1, 2015, are allowable: child care costs and transportation expenses related to direct educational expenses,
training expenses for nursing assistants, and reimbursement for qualified student loan expenses. The amount in the Nursing Facility Related Costs column of this line must tie to the total scholarship expenses reported in section seven of this cost report. Detailed scholarship reporting instructions are located at the end of this document. |
| 7018 |
Report the cost of PERA contributions on this line. |
| 7020 |
Report the cost of Resident & Family Advisory Council Fees on this line. |
| 9021 |
Report the employer contributions to Health Savings Account and Health Reimbursement Arrangements. |
| 9022 |
Report the employer portion of the group medical insurance expense for the reporting period. Do NOT include dental
insurance expense on this line. Per MN Statutes, Section 256B.441, Subd. 11a: "Employer health insurance costs"
means premium expenses for group coverage and reinsurance, actual expenses incurred for self-insured plans, and
employer contributions to employee health reimbursement and health savings accounts. Premium and expense costs and
contributions are allowable for employees who meet the definition of full-time employees and their spouse and
dependents under the federal Affordable Care Act, Public Law 111-148, and part-time employees. |
| 7021 - 7029 |
Record depreciation expense on these lines. Depreciation expense
associated with non-nursing home assets should be removed in the adjustments column (e.g., attached
hospitals, outpatient therapy areas, etc. Refer to "The Estimated Useful Lives of Depreciable Hospital Assets,"
issued by the American Hospital Association for guidance. |
| 7031 |
Facility capital debt and lease interest expense includes all interest and finance charges. It does not include
working capital interest expense. |
| 7051 - 7059 |
Generally, these lines are to be used to record the nursing facility's short-term (less than
one year in length) lease or rental agreement information. Long-term leases and rentals are reported on line 7070.
NOTE: long-term leases that are 12 months in length or greater, but less than $2,000, are to be reported on line 7053.
|
| 7059 |
Rental of off-site space for record storage or other purposes should be
recorded on this line. |
| 7070 |
Report long-term lease expense on this line. Long-term is defined as 12 months or
greater and at least $2,000. |
| 9300 |
The total balance per books should reconcile to total operating expense per
your general ledger. Total operating expenses should equal the total reported for care related, support
services, general and administrative, payroll taxes and benefits, external fixed, depreciation, interest
and lease and rental expense. |
| 9410 - 9440 |
Report all revenue for resident related care on these lines according to
payor source. Revenue reported as an applicable credit in the operating
expense sections of the cost report should be removed in the adjustments column in the revenue section
of the report. Revenue adjustments would also include (be equal to) amounts recorded in the operating
expense sections as an offset (applicable credit) to therapy, pharmacy or other ancillary services.
For example, $500,000 in contract therapy expense was adjusted from allowable expense because therapy
is separately reimbursed. You must enter an adjustment of $500,000 in the revenue section of the report
to reduce the revenue account for that amount.
Medicare or other third party revenue should include the contractual adjustments in the balance per books column rather than the adjustments column.
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| 9450 |
Record other revenue such as vending income, restricted interest income,
revenue not directly related to the operation of the nursing facility, and contributions, etc. on this
line. The adjustments column should be used to remove revenue not directly related to the operation of
the nursing facility. For expenses offset in the operating expense section of the report, for items such
as meal income, beauty shop income, etc., there should be a corresponding revenue adjustment. |
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| 9460 |
Gain or loss on disposition of assets. The gain or loss will be based on the selling price
and either: 1) the original cost or 2) the book value and accumulated depreciation. The sum of book value
and accumulated depreciation is the original cost of an asset. |
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| Net Income |
Balance Per Books "Total Revenue" (line 9400) less Balance Per Books "Total
Operating Expense (line 9300) should equal your "Net Income" on your financial statements. |
| 9510 |
Record the total square footage of the therapy area. |
| 9520 |
"Other Non-nursing Home Area" includes, but is not limited to, assisted living,
day care, coffee shops, etc. In computing the square footage of a non-nursing facility usage area, use inside
wall to inside wall area. |
| 9525 |
Hospital Space refers to the gross square footage of the attached hospital
(the footprint). |
| 9530 |
"Unused Space" includes, but is not limited to, units or wings of the nursing
home no longer used for patient care or storage of equipment/records. |
| 9540 |
Report the gross square footage of the nursing facility less any square footage
already accounted for above. Gross square feet includes both direct assigned (e.g., resident, laundry,
housekeeping) and undefined (common) areas such as hallways,
stairwells, lobby, chapel, and solarium. |
| 1360 - 1369 |
For each type of capital asset listed, record the nursing facility's fiscal
year-end balances and any additions or disposals to those capital assets since the provider's fiscal
year-end to arrive at balances as of the report year-end, September 30, 2015. Disposals should be recorded
as a negative number. Do not record corporate, affiliated, or central office capital assets since
they are not used by the nursing facility in the provision of nursing care services. To determine whether
or not to report an asset in this section depends on whether or not the additions were required to be
capitalized according to GAAP. Hospital-attached facilities that
cannot directly identify changes in the nursing facility’s capital assets are to use the Medicare
step-down method to allocate the costs. |
| 1370 |
Accumulated Depreciation is the sum of all depreciation expense claimed for
all of the facility’s active assets. If an asset is fully depreciated, the cost of the asset is the amount to
report in Accumulated Depreciation as long as that asset is still being used for resident care. Assets that
have been disposed are not to have any value included in Accumulated Depreciation. The facility may have more
than one Accumulated Depreciation value (e.g., one for Medicare, one for taxes, one for books). Report the book
balance on the cost report. In some instances Medicare allows assets to be depreciated above their cost. If you
do not have a book balance and will be reporting the Medicare value, do not include amounts that represent
depreciation above an asset’s cost. |
| 1371 |
Funded depreciation is actual money (cash account) set aside for the replacement
of capitalized assets. |
| General |
All current debts with capital assets pledged as collateral are to be
reported. Detail of working capital debt is not required. Working capital debt interest expense is to
be recorded on line 8050, Net Working Capital Interest Expense. Working capital debt is defined as a loan
that is not secured by capital assets, but is secured by commitments to current assets, such as receivables,
or has no security other than the provider's good name. The provider is to report all debt currently held. Debts recognized for rate setting purposes in the past but not currently held should not be reported. Hospital-attached facilities that do not directly identify the debt associated with the nursing facility’s capital assets are to use the Medicare step-down method to allocate the amounts. Report only the nursing facility share of debt associated with a hospital-attached facility. The identifying code for the loan type created to handle construction project draws over time is "19," referred to as "Construction in Progress (CIP)." The sum of the draws for the reporting year should be reported as negative principal payments for CIP loans. The reporting year that the project is completed a new loan should be reported on the cost report with a new loan code number/type assigned. |
| General |
Loans reported on the prior year's cost report are displayed here. For each existing
loan click on the "Select" button and update the reported information as needed. If a loan is listed and
no longer exists, select the "Delete" button to remove the loan. New debt can be added by selecting the
"Create Loan" button. |
| General |
For all debts, the following are general explanations of the data fields.
|
|
These lines are to be used to record the nursing facility's long-term lease
or rental agreement information. Corporate, affiliated, or central office lease costs for capital assets
not used directly by the nursing facility should not be recorded here. Short-term leases and rentals
(less than one year in length) are reported on line 7051-7059. |
|
| General |
|
ACCRUED VACATION PAY
9/30/XX
| Name | Vacation Hours Balance 9/30/X1 | Hourly Wage 10/1/X1 | Vacation Accrual 9/30/X1 | Vacation Hours Balance 9/30/X2 | Hourly Wage 10/1/X2 | Vacation Accrual 9/30/X2 | Change In Accrued Vacation |
| A.Tarro | 47 | 7.49 | 352.03 | 35 | 7.74 | 270.9 | (81.13) |
| J.Nowon | 27 | 9.49 | 256.23 | 35 | 10.10 | 353.5 | 97.27 |
| J.Cody | 60 | 8.50 | 510.00 | 42 | 9.00 | 378.00 | (132.00) |
| L.Folie | 34 | 6.13 | 208.42 | 35 | 6.33 | 221.55 | 13.13 |
| T.Baron | 19 | 5.00 | 95.00 | 28 | 7.00 | 196.00 | 101.00 |
| O.Dia | 5 | 12.53 | 62.65 | 12 | 13.25 | 159.00 | 96.35 |
| Total | 94.62 |
ACCRUED SICK LEAVE PAY
9/30/XX
| Name | Sick Hours Balance 9/30/X1 | Hourly Wage 10/1/X1 | Sick Accrual 9/30/X1 | Sick Hours Balance 9/30/X2 | Hourly Wage 10/1/X2 | Sick Accrual 9/30/X2 | Change In Accrued Sick Leave |
| A.Tarro | 35 | 7.49 | 262.15 | 42 | 7.74 | 325.08 | 62.93 |
| J.Nowon | 20 | 9.49 | 189.80 | 19 | 10.10 | 191.90 | 2.10 |
| J.Cody | 83 | 8.50 | 705.50 | 57 | 9.00 | 513.00 | (192.50) |
| L.Folie | 45 | 6.13 | 275.85 | 45 | 6.33 | 284.85 | 9.00 |
| T.Baron | 24 | 5.00 | 120.00 | 28 | 7.00 | 196.00 | 76.00 |
| O.Dia | 8 | 12.53 | 100.24 | 10 | 13.25 | 132.50 | 32.26 |
| Total | (10.21) |
Minnesota Statutes, section 256B.431, subdivision 2b, paragraph (g) provides,
"The commissioner shall include the reported actual real estate tax liability or payments in lieu of real estate tax of each nursing home as an operating cost of that nursing home. Allowable costs under this subdivision for payments made by a non-profit nursing home that are in lieu of real estate taxes shall not exceed the amount which the nursing home would have paid to a city or township and county for fire, police, sanitation services, and road maintenance costs had real estate taxes been levied on that property for those purposes."
Facilities claiming amounts for payments in lieu of real estate taxes should be prepared to provide the following upon request by the Department: the tax capacity of the facility (show how the amount is computed); tax capacity rates for fire protection, police, sanitation, and road maintenance; any other information needed to compute the amount paid in lieu of real estate taxes; and a signed statement from the County Assessor, City or Township Clerk, and County Auditor verifying the amounts used for the tax capacity and the tax capacity rates for the four services are correct.
Example calculation:
| SAMPLE CALCULATION OF PAYMENT IN LIEU OF TAXES | ||||||||||||||||||||||||||||||||
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NOTE: This is the maximum that would be allowable. If this is not the actual amount being paid to the county, you will also include the actual amount that will be paid with the information submitted upon request.
| SCHOLARSHIP CONTACT INFORMATION |
In the following three fields, enter contact information for the facility staff
person who works with the Employee Scholarship Program. This should be a staff person who is able to answer
detailed questions about scholarships your facility has awarded. Once you have saved a scholarship record, the
Facility Scholarship Contact Information will automatically “populate” for all subsequent scholarship records you enter.
|
| Contact Name |
Enter NF employee scholarship program facility contact name. |
| Contact Phone |
Enter NF employee scholarship program facility contact telephone number. |
| Contact Email |
Enter NF employee scholarship program contact facility email address. |
| EMPLOYEE DATA |
In the following four fields, enter data on the NF employee receiving the scholarship
award. |
| First Name |
Enter complete employee first name. |
| Last Name |
Enter complete employee last name. |
| Gender |
Select employee gender. |
| Age Range |
Select age range of employee. |
| POSITION DATA |
In the following four fields, enter information about the
position held by the employee at the time they were awarded the scholarship. |
| Position at time of scholarship |
Select employee’s job position at the time the scholarship was
awarded - or "other" if the position is not listed. |
| If "Other" please list |
Enter an explanation if you selected the “other” option for the
employee position. |
| Hourly wage at beginning of the scholarship period |
Enter employee’s hourly wage at the time they were awarded the scholarship
(in dollars and cents with the decimal point (e.g. 9.50)). Do not enter commas or dollar sign ($). |
| Average hours worked/week |
Enter average number of hours employee
worked during the report period. |
| EDUCATIONAL DATA |
The following fields should be completed with information on the nature of
the training the employee was granted a scholarship for. |
| Program or course |
Select an option or "other program"
for the educational/training program the employee is taking. |
| If "28-Other Program" please list |
If you selected "Other Program" (option
28) in the previous field, explain here. |
| Level |
Select the level of the educational
program the employee is taking or select "other." |
| If options 6-8 selected, please explain |
If you selected options 6-8 in the
"Level" field above, you must enter an explanation here. |
| Name of Institution |
Select educational institution or
provider of employee training or select "other" option. |
| If "26 – Other provider" please list |
If you selected "Other Provider" (option
26) in the previous field, explain here. |
| Date Training Began |
Enter the date the course, program or training began in date format
(mm/dd/yyyy). If the course is part of a program track, please enter the program start date - not the
course start date. |
| Has training been completed? |
Select option. |
| If Yes, actual completion date |
Enter actual completion date of training
in date format (mm/dd/yyyy), if known. |
| CAREER ADVANCEMENT |
In the following three fields, enter information about the type of career
advancement that was granted or will be earned by the employee upon completion of the training or
educational program. |
| Career Advancement |
Select the following career advancement option earned by the employee as a
result of their training. If "Wage Increase/Bonus granted" or "Wage Increase/Bonus will be granted upon
completion," the facility must be able to provide documentation in case of an audit. |
| If "Other Advancement" please list |
Explain if you selected "other" in Career Advancement Field. |
| Amount |
Enter the amount of the hourly wage increase or total bonus that was or will
be granted as a result of the employee’s training. Enter dollars and cents with the decimal point.
Do not enter commas or dollar sign ($). |
| ELIGIBLE SCHOLARSHIP EXPENDITURES |
In the following seven fields, enter the amount of eligible facility scholarship
expenditures related to this individual scholarship only. Enter dollars and cents with the decimal point.
Do NOT enter commas or dollar sign ($). |
| Tuition |
Enter facility expenditure for tuition (e.g. 1500.00). This may include training expenses for nursing assistants
(as defined in MN Statutes, Section 144A.611, Subd. 2) if these costs were incurred on/after July 1, 2015. |
| Mandatory Fees |
Enter facility expenditure for mandatory fees (e.g. 30.05). |
| Required Books |
Enter facility expenditure for required books (e.g. 30.40). |
| Required Supplies |
Enter facility expenditure for required supplies (e.g. 30.50). |
| Transportation |
Enter costs for transportation expenses that are related to direct educational expenses and were incurred on or
after July 1, 2015. |
| Day Care |
Enter costs for child care expenses that are related to direct educational expenses and were incurred on or after
July 1, 2015. |
| Student Loan Reimbursement |
Enter the nursing facility cost “to reimburse student loan expenses for newly hired and recently graduated registered
nurses and licensed practical nurses” that were incurred on or after July 1, 2015. For the purposes of the scholarship
program, “newly hired” is defined as an individual hired within the last 12 calendar months. The “hire date” is counted
as the date the individual is offered a job, not their actual start date. “Recently graduated” is defined as having
graduated from nurse aide program within 12 calendar months prior to being offered a job with the facility. |
| Total |
No entries are allowed in this field.
The system will automatically total all previously entered expenditures for this
scholarship record and display the total in this field. |
| Scholarship Contact |
If you have questions about the scholarship program, please contact Munna Yasiri via email at munna.yasiri@state.mn.us |
After each record, click on "check for errors and save record" to save each individual scholarship entry or click on "cancel record" if you do not wish to save this individual scholarship record.
Printing Instructions: On the left hand side of the screen under the "tasks" section, click on the "Print the Cost Report" link. This will open up a "pdf" version of the entire cost report. You have the option to print the entire report or enter the page numbers for the scholarship section alone.