Examples of Data Entry Screens - Welcome To The Oklahoma Health

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					OKLAHOMA HEALTH CARE AUTHORITY                                       DATA ENTRY SCREEN FACSIMILE                     NURSING FACILITY COST REPORT


COST REPORTING MAIN SCREEN



Facility Profile

NHID:                                ###                                         Facility Name:           Facility Name

Provider Number:                  Medicaid #           #########      X          Address 1:                          Address

Organization Type:                Corporation, Not-forProfit, etc.               Address 2:                          Address

Facility Type:                    Adult NF, Aids, MR, or Acute MR                City:        City Name              State:       State       Zip   #####

Admin First Name:                            First Name                          Last Name:                          Last Name

Phone:                                       (###)-###-####                      Previous Facility                   Previous Facility Name

Area:                                        Urban or Rural                      County:                                  County Name



Submit Cost Report
The Current Cost Report is                         07/01/2006 through 06-30-07

Select Reporting Period                        Drop Down Box-Select Current Year                ↓    **              << Edit Cost Report            ***




Notes:                    *The fields in the Facility Profile are populated from the MMIS system automatically.
                          **Select the correct cost report year from the dropdown box; then select Edit Cost Report button to continue.


                          *** Notify Finance Division for any changes to the profile that are needed-but do not wait for these changes before
                              proceeding with data entry.
OKLAHOMA HEALTH CARE AUTHORITY                       DATA ENTRY SCREEN FACSIMILE                   NURSING FACILITY COST REPORT


NURSING HOME COST REPORT MAIN SCHEDULE


Nursing Home ID:         ###    Reporting Period: 07-01-2006 - 06-30-2007 Quarter: Annual             Total Patient Days:         #####

      Complete                           Cost Classification                      Cost Per Day        Total Cost

           √              *     Facility Statistics                                      $ ##.##       ###############                    ↑
           √              *     Salaries & Wages                                         $ ##.##       ###############
           √              *     Outside Professional Fees                                $ ##.##       ###############
           √              *     Employee Expenses                                        $ ##.##       ###############
           √              *     Taxes, Non-Payroll Related                               $ ##.##       ###############
           √              *     Office Expenses                                          $ ##.##       ###############
           √              *     Insurance Non-Payroll                                    $ ##.##       ###############
           √              *     General Expenses                                         $ ##.##       ###############
           √              *     Drugs & Medical Supplies                                 $ ##.##       ###############
           √              *     Capital Related Expenses                                 $ ##.##       ###############
           √              *     Administrative Expenses                                  $ ##.##       ###############
           √              *     Other Expenses                                           $ ##.##       ###############
           √              *     Related Organizations                                    $ ##.##       ###############
                                                    Totals                               $ ##.##       ###############                    ↓

                                                                                                      Send Report           ***


*NH ID, Report Period, QTR, Patient Days, Cost, Cost Per Day, and check (√) marks all populate to this schedule
automatically--use this schedule to manage the report Process.
Enter Data on the selected schedule and then when that schedule is completed the check mark (√) and totals will
report here. The Facility Statistics schedule must be filled out before any others can be chosen.
Do not select Send Report option/button until you are sure that the schedules are correct; once this option has
been chosen the report is locked and you have to contact the finance division to get it unlocked for correction.
OKLAHOMA HEALTH CARE AUTHORITY                                      DATA ENTRY SCREEN FACSIMILE                             NURSING FACILITY COST REPORT


       FACILITY STATISTICS

       Nursing Home ID:             ###(*1)

       Days Report
                                                                    SNF Unit               All Other (NF)                      Total NH
                   Medicare Days                                      ####                         ####                        ####(*1)

                   Medicaid Days                                      ####                         ####                        ####(*1)

                   Other Days                                         ####                         ####                        ####(*1)

       Total Patient Days                                            ####(*1)                     ####(*1)                     ####(*1)

                   Occupancy Rate                                   ##.##%(*1)             Available Bed Days                 ######(*1)

                   Workers Comp                                                      ↓     (*2)           (*3)      Skilled Nursing Facility Addendum

       Ownership
                                                       √        Common Ownership                             (*4)     √     Ownership Change
                                                     Date            ######                       C.O.N. Approval               ######
                   Previous Owner                               Previous Owner's Name
                   Address                       Previous Owner's Address
                   City                                                          State                              Zip


       Related Parties
                                                       √        Related Party Costs                          (*4)     √     Facility Lease
                   Lessor                        Lessor's Name
                   Lessor                        Second Lessor's Name
                   Address                       Lessor's Address
                   City                                                          State                              Zip


                                                                                  Save                              Close
       Notes:      (*1) These items automatically fill/calculate.
                   (*2) Choose the drop down menu and select the type.
                   (*3) Skilled Nursing Facility Addendum must be filled out if SNF days reported--at a minimum Professional Services and
                      Drugs& Medical Supplies should be reported here and not on the other schedules.
                   (*4) If Ownership Change or Facility Lease checked then the Owner./Lessor and address data must be filled out.
OKLAHOMA HEALTH CARE AUTHORITY                             DATA ENTRY SCREEN FACSIMILE                               NURSING FACILITY COST REPORT


     SKILLED NURSING FACILITY ADDENDUM

     Nursing Home ID          ####(*1)                                                                Total Patient Days                             ####(*1)

                            Cost Classification                              Cost Per Day                                 Total Cost

              Salaries & Wages                                                           #####(*1)                        #########                             ↑

              Outside Professional Fees                                                  #####(*1)                        #########

              Employee Benefits                                                          #####(*1)                        #########

              Staff Development & Training                                               #####(*1)                        #########

              Taxes-Non Payroll Related                                                  #####(*1)                        #########

              Office Supplies & Expense                                                  #####(*1)                        #########

              Telephone                                                                  #####(*1)                        #########

              Utilities                                                                  #####(*1)                        #########

              Insurance-Non Payroll Related                                              #####(*1)                        #########

              Dues & Publications                                                        #####(*1)                        #########

              Public Relations                                                           #####(*1)                        #########

              Automobile Expense                                                         #####(*1)                        #########

              Maintenance                                                                #####(*1)                        #########

              Laundry & Linen                                                            #####(*1)                        #########

              Housekeeping                                                               #####(*1)                        #########

              Food & Kitchen Supplies                                                    #####(*1)                        #########

              Social Service Supplies                                                    #####(*1)                        #########

              Drugs & Medical Supplies                                                   #####(*1)                        #########

              Capital Related                                                            #####(*1)                        #########

              Administrative Services                                                    #####(*1)                        #########

              Other Expense                                                              #####(*1)                        #########
                                                                                                                                                                ↓
              Total                                                                      #####(*1)                                  #####(*1)

                                                                                                          Save                        Close

     Notes:   (*1) Populates automatically.
              (*2) At a minimum the costs of "Professional Services" and "Drugs & Medical" should be reported here if the facility reports SNF and
                 these cost are not to be reported on the other schedules.
OKLAHOMA HEALTH CARE AUTHORITY                             DATA ENTRY SCREEN FACSIMILE        NURSING FACILITY COST REPORT


Salaries and Wages

        Nursing Home ID                         ####(*1)                            Total Patient Days               ####(*1)

Direct Care                                     Cost Per Day       Cost Per Hour                 Total Cost           Total Hours
                         Registered Nurses         #####(*1)         #####(*1)                      #########             #########
                 Licensed Practical Nurses         #####(*1)         #####(*1)                      #########             #########
                        Director of Nursing        #####(*1)         #####(*1)                      #########             #########
                                 Nurse Aides       #####(*1)         #####(*1)                      #########             #########
                                  CMA Aides        #####(*1)         #####(*1)                      #########             #########
                                    QMRP's         #####(*1)         #####(*1)                      #########             #########
                           Medical Director        #####(*1)         #####(*1)                      #########             #########
Therapy Services
                         Physical Therapist        #####(*1)         #####(*1)                      #########             #########
                    Occupational Therapist         #####(*1)         #####(*1)                      #########             #########
                     Respiratory Therapist         #####(*1)         #####(*1)                      #########             #########
                          Speech Therapist         #####(*1)         #####(*1)                      #########             #########
                    Therapy Aide/Assistant         #####(*1)         #####(*1)                      #########             #########
Administrative
                                Administrator      #####(*1)         #####(*1)                      #########             #########
                    Assistant Administrator        #####(*1)         #####(*1)                      #########             #########
                   Accountant/Bookkeeper           #####(*1)         #####(*1)                      #########             #########
                          Other Office Staff       #####(*1)         #####(*1)                      #########             #########
Social Services
          Soc. Service Director/Social Worker      #####(*1)         #####(*1)                      #########             #########
                 Other Social Service Staff        #####(*1)         #####(*1)                      #########             #########
                          Activities Director      #####(*1)         #####(*1)                      #########             #########
                      Other Activities Staff       #####(*1)         #####(*1)                      #########             #########
             Comb. Soc Service/Activities          #####(*1)         #####(*1)                      #########             #########
Dietary
                                    Dietician      #####(*1)         #####(*1)                      #########             #########
                        Other Dietary Staff        #####(*1)         #####(*1)                      #########             #########
Housekeeping
           Housekeeping Supervisor                 #####(*1)         #####(*1)                      #########             #########
                       Housekeeping Staff          #####(*1)         #####(*1)                      #########             #########
Maintenance
                  Maintenance Supervisor           #####(*1)         #####(*1)                      #########             #########
                         Maintenance Staff         #####(*1)         #####(*1)                      #########             #########
Laundry
                        Laundry Supervisor         #####(*1)         #####(*1)                      #########             #########
                                Laundry Staff      #####(*1)         #####(*1)                      #########             #########
Other
                           Medical Records         #####(*1)         #####(*1)                      #########             #########
                                       Other       #####(*1)         #####(*1)                      #########             #########
                       Totals                      #####(*1)         #####(*1)                    #####(*1)            #####(*1)
                                                                                                              Save                 Close

Notes: (*1) Enter the total costs and hours -- all other items automatically calculate.
   OKLAHOMA HEALTH CARE AUTHORITY                  DATA ENTRY SCREEN FACSIMILE                   NURSING FACILITY COST REPORT


      Outside Professional Fees

      Nursing Home ID           ####(*1)                                                  Total Patient Days                    ####(*1)

                  Cost Classification                             Cost Per Day                                 Total Cost
                  Contract Registered Nurse                                    ####(*1)                        #########
                  Contract Lic. Practical Nurse                                ####(*1)                        #########
                  Contract Nurse Aides                                         ####(*1)                        #########
                  Medical Director                                             ####(*1)                        #########
                  Therapists                                                   ####(*1)                        #########
                  Consulting Social Worker                                     ####(*1)                        #########
                  Dietician                                                    ####(*1)                        #########
                  Pharmacist                                                   ####(*1)                        #########
                  Dentist                                                      ####(*1)                        #########
                  Accountants                                                  ####(*1)                        #########
                  Legal                                                        ####(*1)                        #########
                  Housekeeping                                                 ####(*1)                        #########
                  Maintenance                                                  ####(*1)                        #########
                  Other                                                        ####(*1)                        #########
                  Computer Programmer                                          ####(*1)                        #########
                                                   Totals                      ####(*1)                              ####(*1)

                                                                                                   Save               Close


Note: Enter dollar amounts--per day costs (*1) will calculate automatically.
   OKLAHOMA HEALTH CARE AUTHORITY                   DATA ENTRY SCREEN FACSIMILE                  NURSING FACILITY COST REPORT


      Employee Expenses

      Nursing Home ID          ####(*1)                                                   Total Patient Days         ####(*1)

      Employee Benefits and Payroll Related Expenses
               Cost Classification                                Cost Per Day                                 Total Cost
      FICA                                                                     ####(*1)                        #########
      Unemployment Compensation Tax                                            ####(*1)                        #########
      Worker's Compensation Insurance                                          ####(*1)                        #########
      Group Health/Dental Insurance                                            ####(*1)                        #########
      Life Insurance                                                           ####(*1)                        #########
      Retirement & Pension                                                     ####(*1)                        #########
      Other Employee Benefits                                                  ####(*1)                        #########

      Staff Development and Training
                  Cost Classification                                          ####(*1)                        #########
      Nurse Aide Competency Evaluation                                         ####(*1)                        #########
      Other Licensed Direct Care Training                                      ####(*1)                        #########
      Other                                                                    ####(*1)                        #########
                                                    Totals                     ####(*1)                              ####(*1)

                                                                                                    Save              Close


Note: Enter dollar amounts--per day costs (*1) will calculate automatically.
   OKLAHOMA HEALTH CARE AUTHORITY                   DATA ENTRY SCREEN FACSIMILE                  NURSING FACILITY COST REPORT


      Taxes-Non-Payroll

      Nursing Home ID          ####(*1)                                                   Total Patient Days         ####(*1)


                  Cost Classification                             Cost Per Day                                 Total Cost
                  Excise Tax                                                   ####(*1)                        #########
                  Corporation License                                          ####(*1)                        #########
                  Ad Valorem                                                   ####(*1)                        #########
                  Auto Tag/Registration                                        ####(*1)                        #########
                  Other                                                        ####(*1)                        #########

                                                    Totals                     ####(*1)                              ####(*1)

                                                                                                    Save              Close


Note: Enter dollar amounts--per day costs (*1) will calculate automatically.
   OKLAHOMA HEALTH CARE AUTHORITY                   DATA ENTRY SCREEN FACSIMILE                  NURSING FACILITY COST REPORT


      Office Expenses

      Nursing Home ID          ####(*1)                                                   Total Patient Days         ####(*1)


                  Cost Classification                             Cost Per Day                                 Total Cost
                  Office Supplies & Expense                                    ####(*1)                        #########
                  Telephone                                                    ####(*1)                        #########
                  Utilities                                                    ####(*1)                        #########



                                                                                                    Save              Close


Note: Enter dollar amounts--per day costs (*1) will calculate automatically.
   OKLAHOMA HEALTH CARE AUTHORITY                   DATA ENTRY SCREEN FACSIMILE                  NURSING FACILITY COST REPORT


      General Expenses

      Nursing Home ID          ####(*1)                                                   Total Patient Days         ####(*1)


                  Cost Classification                             Cost Per Day                                 Total Cost
                  Dues & Publications                                          ####(*1)                        #########
                  Public Relations                                             ####(*1)                        #########
                  Automobile Expenses                                          ####(*1)                        #########
                  Maintenance                                                  ####(*1)                        #########
                  Laundry & Linen                                              ####(*1)                        #########
                  Housekeeping Supplies                                        ####(*1)                        #########
                  Food & Kitchen Supplies                                      ####(*1)                        #########
                  Social Services Supplies                                     ####(*1)                        #########
                                                    Totals                     ####(*1)                              ####(*1)

                                                                                                    Save              Close


Note: Enter dollar amounts--per day costs (*1) will calculate automatically.
   OKLAHOMA HEALTH CARE AUTHORITY                   DATA ENTRY SCREEN FACSIMILE                  NURSING FACILITY COST REPORT


      Insurance Non-Payroll

      Nursing Home ID          ####(*1)                                                   Total Patient Days         ####(*1)


                  Cost Classification                             Cost Per Day                                 Total Cost
                  Building Insurance                                           ####(*1)                        #########
                  Automobile Insurance                                         ####(*1)                        #########
                  Other Insurance                                              ####(*1)                        #########
                                                    Totals                     ####(*1)                              ####(*1)
                  Building Insured Value                              #########
                  Contents Insured Value                              #########

                                                                                                    Save              Close


Note: Enter dollar amounts--per day costs (*1) will calculate automatically.
OKLAHOMA HEALTH CARE AUTHORITY                         DATA ENTRY SCREEN FACSIMILE                   NURSING FACILITY COST REPORT


      Capital Related Expenses

      Nursing Home ID          ####(*1)                                                   Total Patient Days             ####(*1)

      Equipment Rented or Leased          (Includes Auto)
               Landlord-Lessor                           Lease Item              Lease Period                   Current Cost
                                                                                                                  #########
                                                                                                                  #########
                                                                                                                  #########
                                                                                                                  #########
                                                                                                                  #########
                                                                          Equipment Totals                               ####(*1)
      Facilities Rented or Leased
                  Landlord-Lessor                         Lease Item             Lease Period                   Current Cost
                                                                                                                  #########
                                                                                                                  #########
                                                                                                                  #########
                                                                                                                  #########
                                                                                                                  #########
                                                              Facility Administrative Services Totals                    ####(*1)
      Interest Expense
                              Issuance     Maturity      Original Loan        Interest           Principal
        Payee                   Date        Date           Amount                Rate            Balance       Interest Expense
                                                            #########                             #########      #########

                                                            #########                             #########      #########

                                                            #########                             #########      #########

                                                            #########                             #########      #########


                                                            #########                             #########      #########

                                                                                          Interest Totals                ####(*1)

      Depreciation Summary                                                                       Acquisition    Depreciation
                Description                                                                       Cost            Cost
      Buildings & Improvements                                                                    #########      #########

      Local Improvements                                                                          #########      #########

      Leasehold & Improvements                                                                    #########      #########

      Equipment (Moveable, Includes Auto)                                                         #########      #########

                                                                  Depreciation Totals             #########      #########


                                                                            Cost Per Day                          Total Cost
                                                                                       ####(*1)                          ####(*1)

                                                                                                        Save              Close


  Notes: (*1) fields populate automatically.
         Any entry in the lease, rent or Interest expense requires all fields to be populated.
   OKLAHOMA HEALTH CARE AUTHORITY                   DATA ENTRY SCREEN FACSIMILE                  NURSING FACILITY COST REPORT


      Drugs and medical Supplies

      Nursing Home ID          ####(*1)                                                   Total Patient Days         ####(*1)


                  Cost Classification                             Cost Per Day                                 Total Cost
                  Drugs & Medical Supplies                                     ####(*1)                        #########
                  Over-The-Counter Medication                                  ####(*1)                        #########
                  Specialized Adaptive Medical Equipment                       ####(*1)                        #########

                                                    Totals                     ####(*1)                              ####(*1)




                                                                                                    Save              Close


Note: Enter dollar amounts--per day costs (*1) will calculate automatically.
   OKLAHOMA HEALTH CARE AUTHORITY                     DATA ENTRY SCREEN FACSIMILE                    NURSING FACILITY COST REPORT


      Administrative Services

      Nursing Home ID          ####(*1)                                                   Total Patient Days            ####(*1)

      Home Office Expenses
                     Description                                                                                 Total Cost
                                                                                                                  #########
                                                                                                                  #########
                                                                                                                  #########
                                                                                                                  #########
                                                                                                                  #########
                                                                         Home Office Totals                             ####(*1)
      Administrative Services Expenses
      Owner's Non-Salary Compensation                                                                             #########
      Owner's Salary Paid                                                                                         #########
      Benefits on Owner's Salaries                                                                                #########
      Director's Fees                                                                                             #########
      Management Fees Paid                                                                                        #########
                                                              Facility Administrative Services Totals                   ####(*1)

                                                                               Cost Per Day                      Total Cost
                              Administrative Services Totals                              ####(*1)                      ####(*1)

                                                                                                       Save              Close


Note: Enter dollar amounts--per day costs (*1) will calculate automatically.
   OKLAHOMA HEALTH CARE AUTHORITY                   DATA ENTRY SCREEN FACSIMILE                  NURSING FACILITY COST REPORT


      Other Expenses

      Nursing Home ID           ####(*1)                                                  Total Patient Days         ####(*1)


                  Cost Classification                             Cost Per Day                                 Total Cost
                  Hepatitis Vaccination Costs                                  ####(*1)                        #########
                  Provider Fees                                                ####(*1)                        #########
                  Other Costs                                                  ####(*1)                        #########

                                                    Totals                     ####(*1)                              ####(*1)




                                                                                                    Save              Close


Note: Enter dollar amounts--per day costs (*1) will calculate automatically.
OKLAHOMA HEALTH CARE AUTHORITY                   DATA ENTRY SCREEN FACSIMILE                NURSING FACILITY COST REPORT


  Related Organizations

  Nursing Home ID         ####(*1)

  Organization Information                                                                                    % of
            Owner Name                               Related Organization Name                               Ownership




  Related Reported Costs
                         Description of Line on Cost Report Containing Costs                               $ Amount
                                                                                                              #########
                                                                                                              #########
                                                                                                              #########
                                                                                                              #########
                                                                                                              #########

                                                                                               Save                   Close


  Note: This form is to report organizations that the facility purchases goods or services from that is related by common ownership
  or through related parties and where those costs are reported on the cost report.

				
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