{"text_format":"1","workbook":"xlsx","n_sheets":16,"sheets":["CR Main Screen","Facility Statistics","NHCR Main Schedule","SNF Addendum","Salaries & Wages","Outside Professional","Employee Expense","Taxes  NonPayroll","Office Expenses","Insurance-Non_Payroll","General Expenses","Drugs & Medical Supplies","Capital Related Expenses","Administrative Services","Other Expenses","Related Organizations"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":0,"defined_names":0,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"CR Main Screen","index":0,"n_rows":33,"n_cols":12,"rows_kept":33,"cut":false,"hidden":false,"merged":[]}
[]
["OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
["COST REPORTING MAIN SCREEN"]
[]
[]
["Facility Profile"]
[]
["NHID:",null,"XXX",null,null,null,"Facility Name:"]
[]
["Provider Number:",null,"Medicaid # ",null,null,null,"Address 1:"]
[]
["Organization Type:",null,null,null,null,null,"Address 2:"]
["  (Enter Type: Profit or  Not-For-Profit) "]
["Facility Type:",null,null,null,null,null,"City:",null,null,"State:",null,"Zip"]
["  (Enter Type: 1=Aids; 2=Regular NF; 3=Regular ICF/MR; 4=Acute Care ,16 bed or less ICF/MR"]
["Admin First Name:",null,null,null,null,null,"Last Name: "]
[]
["Phone:",null,null,null,null,null,"Previous Facility "]
[]
["Area:(Urban or Rural)",null,null,null,null,null,"County:"]
[]
[]
[]
[]
[]
["The Current Cost Report is",null,"From:"]
[]
[null,null,"To:"]
[]
["Name of Administrator/Owner"]
["Signature of Administrator/Owner"]

{"sheet":"Facility Statistics","index":1,"n_rows":65,"n_cols":11,"rows_kept":65,"cut":false,"hidden":false,"merged":[[57,3,57,5],[49,4,49,5],[49,8,49,9],[51,4,51,5],[51,7,51,8],[53,4,53,6]]}
[]
["OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,null,"    DATA ENTRY SCREEN FACSIMILE",null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,"FACILITY STATISTICS"]
[]
[null,"Nursing Home ID:",null,{"$f":"'CR Main Screen'!C10","v":"XXX"},null,"Medicaid Number",null,{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0}]
[]
[null,"Days Report"]
[null,null,null,null,null,"SNF Unit",null,"All Other (NF)",null,"Total NH"]
[]
[null,null,"Medicare Days",null,null,0,null,0,null,{"$f":"F12+H12","v":0}]
[]
[null,null,"Medicaid Days",null,null,0,null,0,null,{"$f":"F14+H14","v":0}]
[]
[null,null,"Other Days",null,null,0,null,0,null,{"$f":"F16+H16","v":0}]
[]
[null,"Total Patient Days",null,null,null,{"$f":"F12+F14+F16","v":0},null,{"$f":"H12+H14+H16","v":0},null,{"$f":"J12+J14+J16","v":0}]
[]
[null,null,"Occupancy Rate",null,null,"%",null,"Available Bed Days",null,0,"(*1)"]
[]
[null,null,"Workers Comp (*2)"]
[null,null,"(A=Ok State Insurance Fund; B=OK Self Insurance Fund; C=Self-Insured; D=Other)"]
[null,"Ownership"]
[null,null,null,null,null,"Common Ownership(*3)",null,null,null,"Ownership Change(*3)"]
[]
[null,null,null,null,"Date",null,null,"     C.O.N. Approval"]
[]
[]
[null,null,"Previous Owner"]
[]
[null,null,"Address"]
[]
[null,null,"City",null,null,null,"State",null,"Zip"]
[]
[]
[null,"Related Parties"]
[null,null,null,null,null,"Related Party Costs(*3)",null,null,null,"Facility Lease(*3)"]
[]
[null,null,"Lessor"]
[]
[null,null,"Lessor"]
[]
[null,null,"Address"]
[]
[null,null,"City",null,null,null,"State",null,"Zip"]
[]
[]
[null,"LTC Reporting Delegate (Cost Report Preparer)"]
[null,null,"Last Name",null,null,null,null,"First Name"]
[]
[null,null,"Phone",null,null,null,"Email"]
[]
[null,null,"Company Name",null,null,null,null,"Position"]
[]
[null,null,"Address"]
[]
[null,null,"City",null,null,null,"State",null,"Zip"]
[]
[]
[]
[null,"Notes:","(*1)  Should be the total bed days of service if available days were filled 100% of the time."]
[null,null,"(*2)  Enter A,B,C or D as appropriate."]
[null,null,"(*3)  Enter a 1 in the box if this applies to your facility.  That is, if you share common ownership with other facilities, If you had an   "]
[null,null,"  Ownership change during the year, if you purchase services or goods from a related party, or if you lease the facility. "]

{"sheet":"NHCR Main Schedule","index":2,"n_rows":35,"n_cols":11,"rows_kept":35,"cut":false,"hidden":false,"merged":[]}
[]
[null,"OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,"NURSING HOME COST REPORT MAIN SCHEDULE"]
[]
[]
[null,"Nursing Home ID:",null,{"$f":"'CR Main Screen'!C10","v":"XXX"},"Medicaid Number",{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0},null,null,"Total Patient Days:",{"$f":"'Facility Statistics'!J18","v":0}]
[]
[null,null,null,null,"              Cost Classification               ",null,"     Cost Per Day",null,null,"Total Cost"]
[]
[]
[null,null,null,"*","Salaries & Wages",null,null,{"$f":"J13/K8","v":{"$error":"#DIV/0!"}},null,{"$f":"'Salaries & Wages'!L81","v":0}]
[null,null,null,"*","Outside Professional Fees",null,null,{"$f":"J14/K8","v":{"$error":"#DIV/0!"}},null,{"$f":"'Outside Professional'!L41","v":0}]
[null,null,null,"*","Employee Expenses",null,null,{"$f":"J15/K8","v":{"$error":"#DIV/0!"}},null,{"$f":"'Employee Expense'!L37","v":0}]
[null,null,null,"*","Taxes, Non-Payroll Related",null,null,{"$f":"J16/K8","v":{"$error":"#DIV/0!"}},null,{"$f":"'Taxes  NonPayroll'!L24","v":0}]
[null,null,null,"*","Office Expenses",null,null,{"$f":"J17/K8","v":{"$error":"#DIV/0!"}},null,{"$f":"'Office Expenses'!L18","v":0}]
[null,null,null,"*","Insurance Non-Payroll",null,null,{"$f":"J18/K8","v":{"$error":"#DIV/0!"}},null,{"$f":"'Insurance-Non_Payroll'!L18","v":0}]
[null,null,null,"*","General Expenses",null,null,{"$f":"J19/K8","v":{"$error":"#DIV/0!"}},null,{"$f":"'General Expenses'!L28","v":0}]
[null,null,null,"*","Drugs & Medical Supplies",null,null,{"$f":"J20/K8","v":{"$error":"#DIV/0!"}},null,{"$f":"'Drugs & Medical Supplies'!L20","v":0}]
[null,null,null,"*","Capital Related Expenses",null,null,{"$f":"J21/K8","v":{"$error":"#DIV/0!"}},null,{"$f":"'Capital Related Expenses'!M69","v":0}]
[null,null,null,"*","Administrative Expenses",null,null,{"$f":"J22/K8","v":{"$error":"#DIV/0!"}},null,{"$f":"'Administrative Services'!L40","v":0}]
[null,null,null,"*","Other Expenses",null,null,{"$f":"J23/K8","v":{"$error":"#DIV/0!"}},null,{"$f":"'Other Expenses'!L18","v":0}]
[]
[null,null,null,null,null,"Totals",null,{"$f":"J25/K8","v":{"$error":"#DIV/0!"}},null,{"$f":"J13+J14+J15+J16+J17+J18+J19+J20+J21+J22+J23","v":0}]
[]
[]
[]
[]
[null,"*NH ID, Report Period, QTR, Patient Days, Cost, Cost Per Day, and check (√) marks all populate to this schedule"]
[null,"automatically--use this schedule to manage the report Process."]
[null,"Enter Data on the selected schedule and then when that schedule is completed the check mark (√) and totals will "]
[null,"report here.  The Facility Statistics schedule must be filled out before any others can be chosen."]
[null,"Do not select Send Report option/button until you are sure that the schedules are correct; once this option  has"]
[null,"been chosen the report is locked and you have to contact the finance division to get it unlocked for correction."]

{"sheet":"SNF Addendum","index":3,"n_rows":59,"n_cols":11,"rows_kept":59,"cut":false,"hidden":false,"merged":[]}
[]
["     OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,"SKILLED NURSING FACILITY ADDENDUM"]
[]
[null,"Nursing Home ID ",null,{"$f":"'CR Main Screen'!C10","v":"XXX"},"Medicaid No.",{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0},null,"Total Patient Days",null,{"$f":"'Facility Statistics'!J18","v":0}]
[]
[null,null,null,"Cost Classification",null,null,"     Cost Per Day",null,null,"       Total Cost"]
[]
[null,null,"Salaries & Wages",null,null,null,null,{"$f":"J11/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Outside Professional Fees",null,null,null,null,{"$f":"J13/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Employee Benefits",null,null,null,null,{"$f":"J15/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Staff Development & Training",null,null,null,null,{"$f":"J17/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Taxes-Non Payroll Related",null,null,null,null,{"$f":"J19/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Office Supplies & Expense",null,null,null,null,{"$f":"J21/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Telephone",null,null,null,null,{"$f":"J23/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Utilities",null,null,null,null,{"$f":"J25/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Insurance-Non Payroll Related",null,null,null,null,{"$f":"J27/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Dues & Publications",null,null,null,null,{"$f":"J29/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Public Relations",null,null,null,null,{"$f":"J31/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Automobile Expense",null,null,null,null,{"$f":"J33/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Maintenance",null,null,null,null,{"$f":"J35/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Laundry & Linen",null,null,null,null,{"$f":"J37/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Housekeeping",null,null,null,null,{"$f":"J39/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Food & Kitchen Supplies ",null,null,null,null,{"$f":"J41/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Social Service Supplies",null,null,null,null,{"$f":"J43/K7","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Drugs & Medical Supplies"]
[]
[null,null,"Capital Related"]
[]
[null,null,"Administrative Services"]
[]
[null,null,"Other Expense"]
[]
[null,null,"Total",null,null,null,null,{"$f":"J53/K7","v":{"$error":"#DIV/0!"}},null,{"$f":"J11+J13+J15+J17+J19+J21+J23+J25+J27+J29+J31+J33+J35+J37+J39+J41+J43+J45+J47+J49+J51","v":0}]
[]
[]
[]
[null,"Notes: ","(*1)  Populates automatically."]
[null,null,"(*2)  At a minimum the costs of \"Professional Services\" and \"Drugs & Medical\" should be reported here if the facility reports SNF and "]
[null,null,"      these cost are not to be reported on the other schedules."]

{"sheet":"Salaries & Wages","index":4,"n_rows":85,"n_cols":15,"rows_kept":85,"cut":false,"hidden":false,"merged":[]}
[]
["     OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,"Salaries and Wages"]
[]
[null,null,"Nursing Home ID ",null,{"$f":"'CR Main Screen'!C10","v":"XXX"},null,null,null,null,"Total Patient Days",null,null,null,null,{"$f":"'Facility Statistics'!J18","v":0}]
[null,null,"Medicaid No.",null,"          ",{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0},null,null,"          "]
[null,"Direct Care",null,null,"  Cost Per Day",null,null,"  Cost Per Hour",null,null,"     Total Cost",null,null,"     Total Hours"]
[]
[null,null,"Registered Nurses",null,null,{"$f":"L11/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L11/O11","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Licensed Practical Nurses",null,null,{"$f":"L13/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L13/O13","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Director of Nursing ",null,null,{"$f":"L15/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L15/O15","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Nurse Aides",null,null,{"$f":"L17/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L17/O17","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"CMA Aides",null,null,{"$f":"L19/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L19/O19","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"QMRP's ",null,null,{"$f":"L21/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L21/O21","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Medical Director",null,null,{"$f":"L23/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L23/O23","v":{"$error":"#DIV/0!"}}]
[]
[null,"Therapy Services"]
[]
[null,null,"Physical Therapist",null,null,{"$f":"L27/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L27/O27","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Occupational Therapist",null,null,{"$f":"L27/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L29/O29","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Respiratory Therapist",null,null,{"$f":"L31/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L31/O31","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Speech Therapist",null,null,{"$f":"L33/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L33/O33","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Therapy Aide/Assistant",null,null,{"$f":"L3/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L35/O35","v":{"$error":"#DIV/0!"}}]
[]
[null,"Administrative"]
[null,null,"Administrator",null,null,{"$f":"L38/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L38/O38","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Assistant Administrator",null,null,{"$f":"L40/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L40/O40","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Accountant/Bookkeeper",null,null,{"$f":"L42/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L42/O42","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Other Office Staff",null,null,{"$f":"L44/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L44/O44","v":{"$error":"#DIV/0!"}}]
[]
[null,"Social Services"]
[null,null,"Soc. Service Director/Social Worker",null,null,{"$f":"L47/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L47/O47","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Other Social Service Staff",null,null,{"$f":"L49/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L49/O49","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Activities Director",null,null,{"$f":"L51/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L51/O51","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Other Activities Staff",null,null,{"$f":"L53/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L53/O53","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Comb. Soc Service/Activities",null,null,{"$f":"L55/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L55/O55","v":{"$error":"#DIV/0!"}}]
[]
[null,"Dietary"]
[null,null,"Dietician",null,null,{"$f":"L58/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L58/O58","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Other Dietary Staff",null,null,{"$f":"L60/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L60/O60","v":{"$error":"#DIV/0!"}}]
[]
[null,"Housekeeping"]
[null,null,"Housekeeping Supervisor",null,null,{"$f":"L63/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L63/O63","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Housekeeping Staff",null,null,{"$f":"L65/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L65/O65","v":{"$error":"#DIV/0!"}}]
[null,"Maintenance"]
[null,null,"Maintenance Supervisor",null,null,{"$f":"L67/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L67/O67","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Maintenance Staff",null,null,{"$f":"L69/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L69/O69","v":{"$error":"#DIV/0!"}}]
[]
[null,"Laundry"]
[null,null,"Laundry Supervisor",null,null,{"$f":"L72/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L72/O72","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Laundry Staff",null,null,{"$f":"L74/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L74/O74","v":{"$error":"#DIV/0!"}}]
[]
[null,"Other"]
[null,null,"Medical Records",null,null,{"$f":"L77/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L77/O77","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Other",null,null,{"$f":"L79/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L79/O79","v":{"$error":"#DIV/0!"}}]
[]
[null,null,"Totals",null,null,{"$f":"L81/O7","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L81/O81","v":{"$error":"#DIV/0!"}},null,null,{"$f":"L11+L13+L15+L17+L19+L21+L23+L27+L29+L31+L33+L35+L38+L40+L42+L44+L47+L49+L51+L53+L55+L58+L60+L63+L65+L67+L69+L72+L74+L77+L79","v":0},null,null,{"$f":"O11+O13+O15+O17+O19+O21+O23+O27+O29+O31+O33+O35+O38+O40+O42+O44+O47+O49+O51+O53+O55+O58+O60+O63+O65+O67+O69+O72+O74+O77+O79","v":0}]
[]
[]
[]
[null,"Notes:  (*1)  Enter the total costs and hours -- all other items automatically calculate."]

{"sheet":"Outside Professional","index":5,"n_rows":46,"n_cols":14,"rows_kept":46,"cut":false,"hidden":false,"merged":[]}
[]
["     OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,"Outside Professional Fees"]
[]
[null,"Nursing Home ID ",null,{"$f":"'CR Main Screen'!C10","v":"XXX"},null,null,null,null,null,"Total Patient Days",null,null,null,{"$f":"'Facility Statistics'!J18","v":0}]
[null,"Medicaid No.",null,{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0}]
[null,null,"Cost Classification",null,null,null,"          Cost Per Day",null,null,"Cost Per Hour","            Total Cost",null,null,"Total Hours"]
[]
[null,null,"Contract Registered Nurse",null,null,null,null,{"$f":"L11/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L11/N11","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,"Contract Lic. Practical Nurse",null,null,null,null,{"$f":"L13/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L13/N13","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,"Contract Nurse Aides",null,null,null,null,{"$f":"L15/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L15/N15","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,"Medical Director",null,null,null,null,{"$f":"L17/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L17/N17","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,"Therapists",null,null,null,null,{"$f":"L19/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L19/N19","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,"Consulting Social Worker",null,null,null,null,{"$f":"L21/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L21/N21","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,"Dietician",null,null,null,null,{"$f":"L23/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L23/N23","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,"Pharmacist",null,null,null,null,{"$f":"L25/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L25/N25","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,"Dentist",null,null,null,null,{"$f":"L27/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L27/N27","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,"Accountants",null,null,null,null,{"$f":"L29/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L29/N29","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,"Legal",null,null,null,null,{"$f":"L31/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L31/N31","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,"Housekeeping",null,null,null,null,{"$f":"L33/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L33/N33","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,"Maintenance",null,null,null,null,{"$f":"L35/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L35/N35","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,"Other",null,null,null,null,{"$f":"L37/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L37/N37","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,"Computer Programmer",null,null,null,null,{"$f":"L39/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L39/N39","v":{"$error":"#DIV/0!"}},"          #########",0]
[]
[null,null,null,null,null,"Totals",null,{"$f":"L41/N7","v":{"$error":"#DIV/0!"}},null,{"$f":"L41/N41","v":{"$error":"#DIV/0!"}},null,{"$f":"L11+L13+L15+L17+L19+L21+L23+L25+L27+L29+L31+L33+L35+L37+L39","v":0},null,{"$f":"N11+N13+N15+N17+N19+N21+N23+N25+N27+N29+N31+N33+N35+N37+N39","v":0}]
[]
[]
[]
[]
["Note:  Enter dollar amounts--per day costs (*1) will calculate automatically."]

{"sheet":"Employee Expense","index":6,"n_rows":42,"n_cols":12,"rows_kept":42,"cut":false,"hidden":false,"merged":[]}
[]
["     OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,"Employee Expenses"]
[]
[null,"Nursing Home ID ",null,{"$f":"'CR Main Screen'!C10","v":"XXX"},null,null,null,null,"Total Patient Days",null,null,{"$f":"'Facility Statistics'!J18","v":0}]
[null,"Medicaid No.",null,{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0}]
[null,"Employee Benefits and Payroll Related Expenses"]
[null,null,"Cost Classification",null,null,null,"          Cost Per Day",null,null,null,"             Total Cost"]
[]
[null,"FICA",null,null,null,null,null,{"$f":"L12/L7","v":{"$error":"#DIV/0!"}},null,null,"          #########",0]
[]
[null,"Unemployment Compensation Tax",null,null,null,null,null,{"$f":"L14/L7","v":{"$error":"#DIV/0!"}},null,null,"          #########",0]
[]
[null,"Worker's Compensation Insurance",null,null,null,null,null,{"$f":"L16/L7","v":{"$error":"#DIV/0!"}},null,null,"          #########",0]
[]
[null,"Group Health/Dental Insurance ",null,null,null,null,null,{"$f":"L18/L7","v":{"$error":"#DIV/0!"}},null,null,"          #########",0]
[]
[null,"Life Insurance",null,null,null,null,null,{"$f":"L20/L7","v":{"$error":"#DIV/0!"}},null,null,"          #########",0]
[]
[null,"Retirement & Pension",null,null,null,null,null,{"$f":"L22/L7","v":{"$error":"#DIV/0!"}},null,null,"          #########",0]
[]
[null,"Other Employee Benefits",null,null,null,null,null,{"$f":"L24/L7","v":{"$error":"#DIV/0!"}},null,null,"          #########",0]
[]
[]
[null,"Staff Development and Training"]
[]
[null,null,"Cost Classification"]
[]
[null,"Nurse Aide Competency Evaluation",null,null,null,null,null,{"$f":"L31/L7","v":{"$error":"#DIV/0!"}},null,null,"          #########",0]
[]
[null,"Other Licensed Direct Care Training",null,null,null,null,null,{"$f":"L33/L7","v":{"$error":"#DIV/0!"}},null,null,"          #########",0]
[]
[null,"Other",null,null,null,null,null,{"$f":"L35/L7","v":{"$error":"#DIV/0!"}},null,null,"          #########",0]
[]
[null,null,null,null,null,"Totals",null,{"$f":"L37/L7","v":{"$error":"#DIV/0!"}},null,null,null,{"$f":"L12+L14+L16+L18+L20+L22+L24+L31+L33+L35","v":0}]
[]
[]
[]
[]
["Note:  Enter dollar amounts--per day costs (*1) will calculate automatically."]

{"sheet":"Taxes  NonPayroll","index":7,"n_rows":29,"n_cols":12,"rows_kept":29,"cut":false,"hidden":false,"merged":[]}
[]
["     OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,"Taxes-Non-Payroll"]
[]
[null,"Nursing Home ID ",null,{"$f":"'CR Main Screen'!C10","v":"XXX"},null,null,null,null,"Total Patient Days",null,null,{"$f":"'Facility Statistics'!J18","v":0}]
[null,"Medicaid No.",null,{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0}]
[]
[null,null,"Cost Classification",null,null,null,"           Cost Per Day",null,null,null,"             Total Cost"]
[]
[null,null,"Excise Tax",null,null,null,null,{"$f":"L12/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Corporation License",null,null,null,null,{"$f":"L14/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Ad Valorem",null,null,null,null,{"$f":"L16/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Auto Tag/Registration",null,null,null,null,{"$f":"L18/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Other",null,null,null,null,{"$f":"L20/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[]
[]
[null,null,null,null,null,"Totals",null,{"$f":"L24/L7","v":{"$error":"#DIV/0!"}},null,null,null,{"$f":"L12+L14+L16+L18+L20","v":0}]
[]
[]
[]
[]
["Note:  Enter dollar amounts--per day costs (*1) will calculate automatically."]

{"sheet":"Office Expenses","index":8,"n_rows":25,"n_cols":12,"rows_kept":25,"cut":false,"hidden":false,"merged":[]}
[]
["     OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,"Office Expenses"]
[]
[null,"Nursing Home ID ",null,{"$f":"'CR Main Screen'!C10","v":"XXX"},null,null,null,null,"Total Patient Days",null,null,{"$f":"'Facility Statistics'!J18","v":0}]
[null,"Medicaid No.",null,{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0}]
[]
[null,null,"Cost Classification",null,null,null,"     Cost Per Day",null,null,null,"         Total Cost"]
[]
[null,null,"Office Supplies & Expense",null,null,null,null,{"$f":"L12/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Telephone",null,null,null,null,{"$f":"L14/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Utilities",null,null,null,null,{"$f":"L16/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Total Office Expenses",null,null,null,null,{"$f":"L18/L7","v":{"$error":"#DIV/0!"}},null,null,null,{"$f":"L12+L14+L16","v":0}]
[]
[]
[]
[]
[]
[]
["Note:  Enter dollar amounts--per day costs (*1) will calculate automatically."]

{"sheet":"Insurance-Non_Payroll","index":9,"n_rows":27,"n_cols":12,"rows_kept":27,"cut":false,"hidden":false,"merged":[]}
[]
["     OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,"Insurance Non-Payroll"]
[]
[null,"Nursing Home ID ",null,{"$f":"'CR Main Screen'!C10","v":"XXX"},null,null,null,null,"Total Patient Days",null,null,{"$f":"'Facility Statistics'!J18","v":0}]
[null,"Medicaid No.",null,{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0}]
[]
[null,null,"Cost Classification",null,null,null,"          Cost Per Day",null,null,null,"         Total Cost"]
[]
[null,null,"Building Insurance",null,null,null,null,{"$f":"L12/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Automobile Insurance",null,null,null,null,{"$f":"L14/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Other Insurance",null,null,null,null,{"$f":"L16/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,null,null,null,"Totals",null,{"$f":"L18/L7","v":{"$error":"#DIV/0!"}},null,null,null,{"$f":"L12+L14+L16","v":0}]
[]
[null,null,"Building Insured Value",null,null,null,null,0]
[]
[null,null,"Contents Insured Value",null,null,null,null,0]
[]
[]
[]
[]
["Note:  Enter dollar amounts--per day costs (*1) will calculate automatically."]

{"sheet":"General Expenses","index":10,"n_rows":33,"n_cols":12,"rows_kept":33,"cut":false,"hidden":false,"merged":[]}
[]
["     OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,"General Expenses"]
[]
[null,"Nursing Home ID ",null,{"$f":"'CR Main Screen'!C10","v":"XXX"},null,null,null,null,"Total Patient Days",null,null,{"$f":"'Facility Statistics'!J18","v":0}]
[null,"Medicaid No.",null,{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0}]
[]
[null,null,"Cost Classification",null,null,null,"          Cost Per Day",null,null,null,"         Total Cost"]
[]
[null,null,"Dues & Publications",null,null,null,null,{"$f":"L12/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Public Relations",null,null,null,null,{"$f":"L14/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Automobile Expenses",null,null,null,null,{"$f":"L16/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Maintenance",null,null,null,null,{"$f":"L18/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Laundry & Linen",null,null,null,null,{"$f":"L20/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Housekeeping Supplies",null,null,null,null,{"$f":"L22/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Food & Kitchen Supplies",null,null,null,null,{"$f":"L24/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Social Services Supplies",null,null,null,null,{"$f":"L26/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,null,null,null,"Totals",null,{"$f":"L28/L7","v":{"$error":"#DIV/0!"}},null,null,null,{"$f":"L12+L14+L16+L18+L20+L22+L24+L26","v":0}]
[]
[]
[]
[]
["Note:  Enter dollar amounts--per day costs (*1) will calculate automatically."]

{"sheet":"Drugs & Medical Supplies","index":11,"n_rows":29,"n_cols":12,"rows_kept":29,"cut":false,"hidden":false,"merged":[]}
[]
["     OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,"Drugs and medical Supplies"]
[]
[null,"Nursing Home ID ",null,{"$f":"'CR Main Screen'!C10","v":"XXX"},null,null,null,null,"Total Patient Days",null,null,{"$f":"'Facility Statistics'!J18","v":0}]
[null,"Medicaid No.",null,{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0}]
[]
[null,null,"Cost Classification",null,null,null,"     Cost Per Day",null,null,null,"         Total Cost"]
[]
[null,null,"Drugs & Medical Supplies- (Without Oxygen)",null,null,null,null,{"$f":"L12/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Oxygen Only - Including supplies (masks, tubing, etc.)",null,null,null,null,{"$f":"L14/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Over-The-Counter Medication",null,null,null,null,{"$f":"L16/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Specialized Adaptive Medical Equipment",null,null,null,null,{"$f":"L18/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,null,null,null,"Totals",null,{"$f":"L20/L7","v":{"$error":"#DIV/0!"}},null,null,null,{"$f":"L12+L14+L16+L18","v":0}]
[]
[]
[]
[]
[]
[]
[]
[]
["Note:  Enter dollar amounts--per day costs (*1) will calculate automatically."]

{"sheet":"Capital Related Expenses","index":12,"n_rows":77,"n_cols":13,"rows_kept":77,"cut":false,"hidden":false,"merged":[]}
[]
["     OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,null,"Capital Related Expenses"]
[]
[null,null,"Nursing Home ID ",null,{"$f":"'CR Main Screen'!C10","v":"XXX"},null,null,null,null,"Total Patient Days",null,null,{"$f":"'Facility Statistics'!J18","v":0}]
[null,null,"Medicaid No.",null,{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0}]
[]
[null,null,"Equipment Rented or Leased",null,null,"(Includes Auto)"]
[null,null,"            ","Landlord-Lessor",null,null,"     Lease Item",null,"    Lease Period",null,null,null,"     Current Cost"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,"Equipment Totals",null,null,null,{"$f":"M13+M15+M17+M19+M21","v":0}]
[]
[null,null,"Facilities Rented or Leased"]
[null,null,"            ","Landlord-Lessor",null,null,"     Lease Item",null,"    Lease Period",null,null,null,"     Current Cost"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,"Facility Administrative Services Totals",null,null,null,{"$f":"M28+M30+M32+M34+M36","v":0}]
[]
[null,null,"Interest Expense"]
[null,null,null,null,"Issuance","Maturity",null,"    Original Loan","Interest",null,"       Principal"]
[null,null,"Payee",null,"Date","Date",null,"            Amount","Rate",null,"        Balance",null,"   Interest Expense"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,"Interest Totals",null,null,{"$f":"M44+M46+M48+M50+M52","v":0}]
[]
[null,null,"Depreciation Summary",null,null,null,null,null,null,null,"      Acquisition",null,"      Depreciation"]
[null,null,null,"Description",null,null,null,null,null,null,"        Cost",null,"           Cost"]
[]
[null,null,"Buildings & Improvements"]
[]
[null,null,"Local Improvements"]
[]
[null,null,"Leasehold & Improvements"]
[]
[null,null,"Equipment (Moveable, Includes Auto)"]
[]
[null,null,null,null,null,null,null,"Depreciation Totals",null,null,{"$f":"K59+K61+K63+K65","v":0},null,{"$f":"M59+M61+M63+M65","v":0}]
[]
[null,null,null,null,null,null,null,"Total Capital Costs",null,null,null,null,{"$f":"M23+M38+M54+M67","v":0}]
[null,null,null,null,null,null,null,"Per Day Capital Costs",null,null,null,null,{"$f":"M69/M7","v":{"$error":"#DIV/0!"}}]
[]
[]
[]
[]
[null,"Notes: (*1) fields populate automatically."]
[null,null,"     Any entry in the lease, rent or Interest expense requires all fields to be populated."]
[null,null,"    "]

{"sheet":"Administrative Services","index":13,"n_rows":45,"n_cols":12,"rows_kept":45,"cut":false,"hidden":false,"merged":[]}
[]
["     OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,"Administrative Services"]
[]
[null,"Nursing Home ID ",null,{"$f":"'CR Main Screen'!C10","v":"XXX"},null,null,null,null,"Total Patient Days",null,null,{"$f":"'Facility Statistics'!J18","v":0}]
[null,"Medicaid No.",null,{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0}]
[]
[null,"Home Office Expenses"]
[null,null,"          Description",null,null,null,null,null,null,null,"         Total Cost"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,"Home Office Totals",null,null,null,{"$f":"L13+L15+L17+L19+L21","v":0}]
[]
[null,"Administrative Services Expenses"]
[]
[null,"Owner's Non-Salary Compensation"]
[]
[null,"Owner's Salary Paid"]
[]
[null,"Benefits on Owner's Salaries"]
[]
[null,"Director's Fees"]
[]
[null,"Management Fees Paid"]
[]
[null,null,null,null,null,null,null,"Facility Administrative Services Totals",null,null,null,{"$f":"L27+L29+L31+L33+L35","v":0}]
[]
[null,null,null,null,null,null,null,"Cost Per Day",null,null,"         Total Cost"]
[null,null,null,"Administrative Services Totals",null,null,null,{"$f":"L40/L7","v":{"$error":"#DIV/0!"}},null,null,null,{"$f":"L37+L23","v":0}]
[]
[]
[]
[]
["Note:  Enter dollar amounts--per day costs (*1) will calculate automatically."]

{"sheet":"Other Expenses","index":14,"n_rows":27,"n_cols":12,"rows_kept":27,"cut":false,"hidden":false,"merged":[]}
[]
["     OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,"Other Expenses"]
[]
[null,"Nursing Home ID ",null,{"$f":"'CR Main Screen'!C10","v":"XXX"},null,null,null,null,"Total Patient Days",null,null,{"$f":"'Facility Statistics'!J18","v":0}]
[null,"Medicaid No.",null,{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0}]
[]
[null,null,"Cost Classification",null,null,null,null,"     Cost Per Day",null,null,"         Total Cost"]
[]
[null,null,"Hepatitis Vaccination Costs",null,null,null,null,{"$f":"L12/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Provider Fees",null,null,null,null,{"$f":"L14/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,"Other Costs",null,null,null,null,{"$f":"L16/L7","v":{"$error":"#DIV/0!"}},null,null,null,0]
[]
[null,null,null,null,null,"Totals",null,{"$f":"L18/L7","v":{"$error":"#DIV/0!"}},null,null,null,{"$f":"L12+L14+L16","v":0}]
[]
[]
[]
[]
[]
[]
[]
[]
["Note:  Enter dollar amounts--per day costs (*1) will calculate automatically."]

{"sheet":"Related Organizations","index":15,"n_rows":43,"n_cols":11,"rows_kept":43,"cut":false,"hidden":false,"merged":[]}
[]
["     OKLAHOMA HEALTH CARE AUTHORITY",null,null,null,null,"DATA ENTRY SCREEN FACSIMILE",null,null,null,"NURSING FACILITY COST REPORT"]
[]
[]
[null,"Related Organizations"]
[]
[null,"Nursing Home ID ",null,{"$f":"'CR Main Screen'!C10","v":"XXX"}]
[null,"Medicaid No.",null,{"$f":"'CR Main Screen'!D12","v":0},{"$f":"'CR Main Screen'!E12","v":0}]
[]
[null,"Organization Information",null,null,null,null,null,null,null,null,"            % of "]
[null,null,"Owner Name",null,null,"      Related Organization Name",null,null,null,null,"         Ownership"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"Related Reported"]
[]
[null,null,null,"Description of Cost Report Line Containing Costs ",null,null,null,null,null,null,"      $ Amount"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"Note:  This form is to report organizations that the facility purchases goods or services from that is related by common ownership"]
[null,"or through related parties and where those costs are reported on the cost report."]