{"text_format":"1","workbook":"xlsx","n_sheets":4,"sheets":["Part I","Part II","Part III","Part IV"],"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":"Part I","index":0,"n_rows":87,"n_cols":13,"rows_kept":87,"cut":false,"hidden":false,"merged":[[53,3,53,4],[36,3,38,13],[41,3,43,13],[46,3,48,13],[23,3,24,13],[52,9,52,13],[51,3,51,9],[30,3,30,13],[35,3,35,13],[40,3,40,13],[45,3,45,13],[25,3,27,13],[31,3,33,13],[67,3,67,13],[66,3,66,13],[58,4,58,9],[61,4,61,9],[64,3,64,13],[68,3,68,13],[76,4,76,9],[83,4,83,9],[86,4,86,9],[69,3,69,13],[71,3,71,13],[72,3,72,13],[73,3,73,13],[19,3,21,13],[0,0,0,13],[1,0,1,13],[2,0,2,13],[8,4,8,8],[9,4,9,8],[10,4,10,8],[11,4,11,8],[12,4,12,8],[13,4,13,8],[16,3,16,7]]}
["DEPARTMENT OF COMMUNITY HEALTH"]
["FAIR RENTAL VALUE SYSTEM "]
["INITIAL START UP AND FAIR RENTAL VALUE (FRV) REIMBURSEMENT UPDATE REQUEST FORM"]
[]
[]
[null,"DATE COMPLETED:"]
[]
[null,null,null,"Contact Information"]
[null,null,null,"Nursing Facility Name"]
[null,null,null,"Provider Number"]
[null,null,null,"Address"]
[null,null,null,"City, State, ZIP"]
[null,null,null,"Administrator"]
[null,null,null,"Phone Number "]
[]
[]
[null,null,null,"Provide explanation of renovation project submission"]
[]
[null,null,null,"New Construction"]
[]
[]
[]
[]
[null,null,null,"Gut and Rebuild [Involves major restoration to the entire facility in the form of removing all fixtures, materials and everything else down to the studs and then building it back up. (See instructions)]"]
[]
[]
[]
[]
[]
[null,null,null,"Renovation"]
[null,null,null,"Addition (with square footage update)"]
[]
[]
[]
[]
[null,null,null,"Update or improvement to patient rooms/common rooms/offices/etc."]
[]
[]
[]
[]
[null,null,null,"Update or improvement to equipment (HVAC/Water Heaters/Nurse Call Stations/Telephone System/Kitchen/etc.)"]
[]
[]
[]
[]
[null,null,null,"Update to electrical system or plumbing system in facility"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"Yes",null,"No"]
[null,null,null,"Has this project been submitted to Office of Health Planning for review and approval?"]
[]
[null,null,null,"Person Completing the Form:"]
[]
[null,null,null,"Name:"]
[]
[]
[null,null,null,"Title"]
[]
[]
[null,null,null,"Date"]
[]
[]
[null,null,null,"CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER"]
[]
[null,null,null,"MISREPRESENTATION OR FALSIFICATION"]
[null,null,null,"OF ANY INFORMATION CONTAINED IN THIS "]
[null,null,null,"FAIR RENTAL VALUE SYSTEM REIMBURSEMENT REPORT MAY BE PUNISHABLE BY FINE"]
[null,null,null,"AND/OR IMPRISONMENT UNDER STATE OR FEDERAL LAW"]
[]
[null,null,null,"I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying Fair Rental Value System "]
[null,null,null,"Reimbursement Report and supporting schedules, and that to the best of my knowledge and belief, it is a true, correct, and "]
[null,null,null,"complete statement prepared from the books and records of the facility in accordance with applicable instructions, except as noted."]
[]
[]
[null,null,null,"Name:"]
[]
[]
[null,null,null,"1.",null,"Owner",null,"3.",null,"Administrator"]
[null,null,null,"2.",null,"Officer"]
[]
[]
[null,null,null,"Title"]
[]
[]
[null,null,null,"Date"]

{"sheet":"Part II","index":1,"n_rows":14,"n_cols":3,"rows_kept":14,"cut":false,"hidden":false,"merged":[[13,2,15,7]]}
[null,"Part II - Facility Information "]
[]
[null,null,"Year of Construction"]
[null,null,"Number of licensed beds after initial construction of the Nursing Facility"]
[null,null,"Total Number of Licensed Nursing Facility Beds"]
[]
[null,null,"Total Number of Non-Nursing Facility Beds (Assisted Living, Residential)*"]
[null,null,"Total Square Footage of Facility"]
[null,null,"Total Square Footage Applicable to Nursing Facility"]
[null,null,"Total Square Footage Applicable to Non-Nursing Facility*"]
[]
[]
[]
[null,null,"Note *  Non-Nursing Facility Services relate to other services that your facility may provide that are not typical nursing facility services.  Types of Non-Nursing Facility services include Assisted Living and Residential Care Units.  The square footage area and beds used for providing non-nursing services should be reported separately above."]

{"sheet":"Part III","index":2,"n_rows":33,"n_cols":7,"rows_kept":33,"cut":false,"hidden":false,"merged":[[2,1,3,10]]}
[null,"Part III - Bed Additions or Replacements"]
[]
[null,"When completing the Part III and Part IV, include data from the buildings initial year of construction to present.  This could involve reviewing prior owner's records, or in the case of a lease, obtaining information from the lessor.  The month and year of project completion should reflect the month the beds were added or replaced in the facility."]
[]
[]
[]
[null,null,"PROJECT _____________",null,null,null,"PROJECT _____________"]
[null,null,"Month/Year of Project Completion",null,null,null,"Month/Year of Project Completion"]
[null,null,"Beginning number of Licensed Facility Beds",null,null,null,"Beginning number of Licensed Facility Beds"]
[null,null,"Number of New Beds Added (if applicable)",null,null,null,"Number of New Beds Added (if applicable)"]
[null,null,"Number of Replacement Beds (if applicable)",null,null,null,"Number of Replacement Beds (if applicable)"]
[null,null,"Square footage added due to completion of project",null,null,null,"Square footage added due to completion of project"]
[]
[null,null,"PROJECT _____________",null,null,null,"PROJECT _____________"]
[null,null,"Month/Year of Project Completion",null,null,null,"Month/Year of Project Completion"]
[null,null,"Beginning number of Licensed Facility Beds",null,null,null,"Beginning number of Licensed Facility Beds"]
[null,null,"Number of New Beds Added (if applicable)",null,null,null,"Number of New Beds Added (if applicable)"]
[null,null,"Number of Replacement Beds (if applicable)",null,null,null,"Number of Replacement Beds (if applicable)"]
[null,null,"Square footage added due to completion of project",null,null,null,"Square footage added due to completion of project"]
[]
[null,null,"PROJECT _____________",null,null,null,"PROJECT _____________"]
[null,null,"Month/Year of Project Completion",null,null,null,"Month/Year of Project Completion"]
[null,null,"Beginning number of Licensed Facility Beds",null,null,null,"Beginning number of Licensed Facility Beds"]
[null,null,"Number of New Beds Added (if applicable)",null,null,null,"Number of New Beds Added (if applicable)"]
[null,null,"Number of Replacement Beds (if applicable)",null,null,null,"Number of Replacement Beds (if applicable)"]
[null,null,"Square footage added due to completion of project",null,null,null,"Square footage added due to completion of project"]
[]
[null,null,"PROJECT _____________",null,null,null,"PROJECT _____________"]
[null,null,"Month/Year of Project Completion",null,null,null,"Month/Year of Project Completion"]
[null,null,"Beginning number of Licensed Facility Beds",null,null,null,"Beginning number of Licensed Facility Beds"]
[null,null,"Number of New Beds Added (if applicable)",null,null,null,"Number of New Beds Added (if applicable)"]
[null,null,"Number of Replacement Beds (if applicable)",null,null,null,"Number of Replacement Beds (if applicable)"]
[null,null,"Square footage added due to completion of project",null,null,null,"Square footage added due to completion of project"]

{"sheet":"Part IV","index":3,"n_rows":42,"n_cols":11,"rows_kept":42,"cut":false,"hidden":false,"merged":[[5,2,7,9],[38,2,39,9],[41,2,43,9],[2,2,3,10]]}
[null,"Part IV - Renovation/Construction Projects"]
[]
[null,null,"When completing the Part III and Part IV, include data from the buildings initial year of construction to present.  This could involve reviewing prior owner's records, or in the case of a lease, obtaining information from the lessor.  The month and year of project completion should reflect the month the beds were added or replaced in the facility."]
[]
[]
[null,null,"Renovation/Construction Projects have a total cost that exceeds $500 per licensed bed at the time the project was completed.  If a renovation/construction project involved construction activities in both the licensed nursing facility and the non-nursing facility sections of the facility, only those construction costs associated with the licensed section of the facility should be included (Note:  Documentation must be submitted with this form that demonstrates how the construction costs were allocated between the Nursing Facility and the Non-Nursing Facility Services Section)."]
[]
[]
[]
[null,null,"Renovation/Construction Project Threshold Determination:"]
[null,null,"Number of Licensed Beds "]
[null,null,"Cost Per Bed Threshold",500]
[null,null,"Project Determination Amount",{"$f":"+D11*D12","v":0},"(Construction cost of project must exceed this amount)"]
[]
[null,null,"RENOVATION  ___________",null,null,null,"RENOVATION  ________"]
[null,null,"Renovation/Construction Start Date ",null,null,{"$f":"IF(E16<+(E17-366),\"Project must be completed over a 12 month period.\",\" \")","v":" "},"Renovation/Construction Start Date ",null,null,null,{"$f":"IF(J16<+(J17-366),\"Project must be completed over a 12 month period.\",\" \")","v":" "}]
[null,null,"Renovation/Construction Completion Date",null,null,null,"Renovation/Construction Completion Date"]
[null,null,"Cost of Renovation (construction costs) **",null,null,null,"Cost of Renovation (construction costs) **"]
[null,null,"Square footage added due to completion of renovation",null,null,null,"Square footage added due to completion of renovation"]
[]
[null,null,"RENOVATION  ___________",null,null,null,"RENOVATION  ________"]
[null,null,"Renovation/Construction Start Date ",null,null,{"$f":"IF(E22<+(E23-366),\"Project must be completed over a 12 month period.\",\" \")","v":" "},"Renovation/Construction Start Date ",null,null,null,{"$f":"IF(J22<+(J23-366),\"Project must be completed over a 12 month period.\",\" \")","v":" "}]
[null,null,"Renovation/Construction Completion Date",null,null,null,"Renovation/Construction Completion Date"]
[null,null,"Cost of Renovation (construction costs) **",null,null,null,"Cost of Renovation (construction costs) **"]
[null,null,"Square footage added due to completion of renovation",null,null,null,"Square footage added due to completion of renovation"]
[]
[null,null,"RENOVATION  ___________",null,null,null,"RENOVATION  ________"]
[null,null,"Renovation/Construction Start Date ",null,null,{"$f":"IF(E28<+(E29-366),\"Project must be completed over a 12 month period.\",\" \")","v":" "},"Renovation/Construction Start Date ",null,null,null,{"$f":"IF(J28<+(J29-366),\"Project must be completed over a 12 month period.\",\" \")","v":" "}]
[null,null,"Renovation/Construction Completion Date",null,null,null,"Renovation/Construction Completion Date"]
[null,null,"Cost of Renovation (construction costs) **",null,null,null,"Cost of Renovation (construction costs) **"]
[null,null,"Square footage added due to completion of renovation",null,null,null,"Square footage added due to completion of renovation"]
[]
[null,null,"RENOVATION  ___________",null,null,null,"RENOVATION  ________"]
[null,null,"Renovation/Construction Start Date ",null,null,{"$f":"IF(E34<+(E35-366),\"Project must be completed over a 12 month period.\",\" \")","v":" "},"Renovation/Construction Start Date ",null,null,null,{"$f":"IF(J34<+(J35-366),\"Project must be completed over a 12 month period.\",\" \")","v":" "}]
[null,null,"Renovation/Construction Completion Date",null,null,null,"Renovation/Construction Completion Date"]
[null,null,"Cost of Renovation (construction costs) **",null,null,null,"Cost of Renovation (construction costs) **"]
[null,null,"Square footage added due to completion of renovation",null,null,null,"Square footage added due to completion of renovation"]
[]
[null,null,"Note ** Renovation/Construction Projects include those items capitalized in accordance with Section 108.1 and 108.2 of the Provider Reimbursement Manual and CMS Publication 15-1 to include Buildings, Machinery, Fixtures, and Fixed Equipment."]
[]
[]
[null,null,"IMPORTANT:  For the purpose of this report and the $500 per bed test, different projects (completed in a 12 month period) may be combined.  For example, if a roof was replaced and flooring was replaced, these costs may be combined into a single project.  If all Capital Improvements made (completed in a 12 month period) exceed the $500 per bed test, they should be included as a renovation/construction project."]