Minnesota Department of Human Services

Instruction Manual

Annual Statistical and Cost Report
of Nursing Facilities

For the Reporting Year Ending September 30, 2014

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 2014 COST REPORTING?

Physical Plant Owner
The physical plant owner field must have a valid selection. Please note that Real Estate Investment Trust (REIT) has been added to the drop-down menu.

Unions
This field must be completed by providers whose employees are covered by bargaining units. List all of the unions that cover employees in the nursing facility.

Line 7016, Long-Term Care Consultations (LTCC)
This line has been removed from the cost report as nursing facilities are no longer required to make payments to the counties to cover the cost of this service.

Employee Data Section: Employee Health Insurance and the Affordable Care Act (ACA)
This section of the Cost Report Instruction Manual has been significantly changed in an effort to simplify reporting. All data must be for one month during the cost report period. The selected month that is being used will be referred to as the “Data Month”.

Line 1619- 1638, Direct Care Staff Retention, Column 1.
This part of the Cost Report Instruction Manual has been changed. Now employees that change jobs from a classification shown on this table to a classification not shown on this table (certified nursing assistant to dietary, for example), cannot be included in the count of employees still employed at the end of the reporting year in the same classification they started the year.

Line 6213, Other Care Related Staff
The Cost Report Instructions have been updated to specify that these costs are to include non-licensed and non-certified therapy aides.

Line 8049, Property Insurance
The classifications of insurance costs were updated to provide greater detail and direction. The property insurance costs identified now include flood insurance, Inland Marine, and MN Fire Surcharge.

Line 9021, Health Savings Account (HSA)
This is a new line where Providers are to report the employer contributions to Health Savings Account and Health Reimbursement Arrangements. This is a change from previous directions to include this expense on line 9080.

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 Statue. These changes pertain to the use of “direct care.” The Minnesota Nursing Home Report Card will be updated to reflect these changes as well. 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 (1635), Social Workers (1636), Activities (1637) and Other Care Related Staff (1638) | calculate the other care-related per diem of the operating rate | 256B.442, Subd. 28a and Subd. 48

## GENERAL INSTRUCTIONS

The deadline for submission of the Annual Report is 11:59 pm on February 2, 2015.

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 on line, 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.

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, 2014.

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 8049 – Property 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 9/30/14 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, a drop down menu will automatically appear. 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.

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.

## General Information

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 Information

Facility 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: 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.

Admissions during report year: Record the total number of NF and NFII resident admissions (Medicaid and non-Medicaid).

Licensed name of business 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.

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.

Number of facilities: The Minnesota facilities line must be at least "1" (for this facility).

Beds Data

General | The Licensed & Certified Beds section is for the recording of bed status and the types of changes to bed status during the reporting year.
0090 | The number of licensed beds in active service on the first day of the reporting year has been pre-filled based on the information reported at the end of the previous report year. Active service means beds that are being used by a resident or can be filled by a resident at any time.
0095 | The number of licensed beds in layaway status on the first day of the reporting year has been pre-filled based on the information reported at the end of the previous cost report year.
| Change in number of beds
| This section is to record changes in bed status during the reporting year. Any bed changes that occurred after 9/30/13 and before 10/1/14 have been presented for you to review and edit if necessary. Record changes in bed status by type of change, the date of change, and the number of beds changed. The codes for change type are:
| Beds placed on lay away Beds removed from lay away and placed back in service Beds de-licensed Beds relocated from another facility to this facility
| Record all bed changes as positive values.
| If beds previously placed on layaway were delicensed during this reporting period, first record the removal of beds from layaway and then record the de-licensed beds.
0264 - 0268 | Single-bed rooms are those where a bed does not share access to the corridor with another bed. A private room is a single-bed room that has a toilet area that it does not share with another bed. Two single-bed rooms that have a toilet area between them and each bed has a door to the toilet area are not private rooms; they are to be reported as single-bed rooms.
| Split-double rooms are those where two beds share access to the corridor, but there is a fixed, floor to ceiling, partition that physically splits the room in two.
| Double-bed rooms are those where two beds share access to the corridor and there is no fixed partition separating the beds.
| Three- and four-bed rooms are those where the given number of beds shares access to the corridor.
| When completing this table, enter the number of beds in each of these configurations as of the last day of the reporting period and not the number of rooms. Do not report beds that have been put on layaway.
| Bed configurations from the prior report year are displayed for your review. If the bed configurations reported on your previous cost report contains an error, please contact the department.
0273 | Record the number of Medicare-certified skilled beds at the end of the reporting year.

Single/Private-bed room Differentials

| Report the amount(s) currently charged for a single-bed room (a.k.a., the private room differential).

Nursing Home Resident Days

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, 2013 through September 30, 2014. 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.

BC Patient Days

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.

## Employee Data

Care Related Staff Retention

1619 - 1638 | In column 1, record the number of employees on October 1, 2013. 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.
| 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.
| 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.
| 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.
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, 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, 2013 that were still employed on September 30, 2014 divided by the number of care related employees on October 1, 2013.

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. The time studies must meet the following criteria: A minimally acceptable time study must encompass at least one full week per six month period of the reporting period. The weeks selected should vary among the two required weeks, e.g., one the first week of the month, one the third week of the month The time study should not occur in two consecutive months. The time study must be contemporaneous with the costs to be allocated. Thus, a time study conducted in the current cost reporting year may not be used to allocate the costs of prior or subsequent cost reporting years. The time study must be facility specific. Thus, chain organizations may not use a time study from one facility to allocate the costs of another facility or a time study of a sample group of facilities to allocate the costs of all facilities within the chain
| The following exceptions are not to be reported as productive hours:
| Medical records personnel time must be excluded from “Productive Hours.” Non-licensed nursing administrative staff such as unit coordinators and schedulers must be excluded from productive hours. Vacation, holiday, sick leave, classroom training and meal breaks should be excluded in this computation, but coffee breaks should be included. Volunteer hours.

0312 - 0315 | The hours for internal pool staff that are on the facility's payroll are NOT to be reported here. These lines are for reporting external staffing hours only, Supplemental Nursing Services Agency (SNSA).
0316 | Report interim nursing administration support hours from consulting firm staff here. SNSA hours are NOT to be reported here.
0320 | Record productive hours for Other Care Related Staff on this line. Other Care Related Staff includes any nursing employees who do not fit into Nursing Administration, RN, LPN, C.N.A. or TMA categories. Do not include medical records personnel. Include any other staff providing care related services to residents such as feeding assistants and religious personnel. Dietary aides are not to be included. Do not include licensed therapists or their assistants performing separately billable services including Medicare Part A and B or other third party payor.

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.

4. | Resident days include NF days and NFII days (Report lines 5001 to 5100). Both regular and pool productive hours are included (Report lines 0301 to 0320). Productive hours are converted into Hours per Resident Day figures: RN hours / resident days, LPN hours / resident days, etc. The following job classifications are considered direct care staff for the purposes of assigning stars on the MN Nursing Home Report Card for the direct care staff hours per day measure. Hours per Resident Day are weighted for relative cost per staff type (statewide average salary ratios):
   Staff type |  | Ratio
   DON/Nurse administrator |  | 2.32
   RN |  | 2.02
   LPN |  | 1.51
   Certified Nursing Assistant |  | 1.00
   TMA |  | 1.13
   Mental health worker |  | 1.10
   Social worker |  | 1.58
   Activity staff |  | 1.12
   Other care related staff |  | 1.47
5. Sum of cost weighted hours =
   | (DON hrs paid * DON cost wt) + (RN hrs paid * RN cost wt) + (LPN hrs paid * LPN cost wt) + (C.N.A. hrs paid * C.N.A. cost wt) + (TMA hrs paid * TMA cost wt) + (MH hrs paid * MH cost wt) + (SW hrs paid * SW cost wt) + (ACT hrs paid * ACT cost wt) + (OTH hrs paid * OTH cost wt).
Sum of cost-weighted hours is adjusted for facility average acuity: Adjusted Hrs paid = (Sum of cost weighted hours) / average acuity.

Compensated Hours

0330 - 0388 | Record the hours paid by employee classifications. Paid vacation, sick, holiday hours, etc., should be included. Compensated hours should be equal to or greater than productive hours reported on lines 0301-0320. Compensated hours must be allocated to care related hours according to the same methodology adopted for allocation of productive hours and salary expense for those employees performing both care related and support services. In order to accurately compute average hourly rates, it is important that compensated hours for care related workers are classified in the same category that their associated salaries are reported. For example, if the salary for a Universal worker has been allocated between C.N.A. salaries and support services salary, the compensated hours for the C.N.A. on line 0380 should reflect the same proportion used to allocate the salary. The reported salary cost per compensated hour calculation for Nursing Administration includes both lines 6111 and 6260.

Other Employee Information: Employment Status

0401 - 0414 | Record the total number of employees by employment status as of the last day of this reporting period as either FT (full-time) or PT (part-time). The term “full-time employee” means, an employee who is employed on average at least 30 hours of service per week. Report the number of workers, not by FTEs. Exclude temporary workers, on-call staff, casual workers and contract workers.

Employee Health Insurance and the Affordable Care Act (ACA)

General | All data must be for one month during the cost report period. We will call this the “Data Month”. Indicate whether the nursing facility offered employee health insurance during the Data Month. If the response is yes, you will be prompted to provide additional information: Enter the selected month that is being used as the Data Month. Of the Total Employees, enter the number of employees that were eligible for health insurance during the Data Month. Using the drop down menu, indicate whether the number of employees eligible for health insurance were determined based on ACA eligibility criteria or employer defined eligibility criteria.
Add A Record | Click the ‘Add A Record’ button to provide additional information pertaining to employee health insurance coverage.
ACA Questions | Type: Select from the drop down menu, one of the available options. If none of the types fit, use Other. If you have more than one plan that fits that type, you can use an average premium amount for all the plans or you can add more than one record with the same type. Samples of Types – the types are not limited to these samples: Employee + 1 = Employee & Spouse, Employee & Domestic Partner, Employee & child or other dependent Employee + 2 or more = Employee, Spouse/Domestic Partner & child(ren) or other dependents Family = Employee, Spouse/Domestic Partner & child(ren) or other dependents, if the insurance does not break out by above categories or if specifically designated by the insurance Total Premium Amount: Enter the monthly/semi-monthly/bi-weekly premium for one employee. If using an average premium please add up the amount paid for the insurance type during the Data Month and divide by number of participants. Premium Frequency: Select from the drop down menu the premium frequency monthly/semi-monthly/bi-weekly premium. Employer Contribution Amount: Enter the monthly/semi-monthly/bi-weekly amount of the premium the employer pays for one employee. If using an average premium add up the total amount paid by the employer and divide by the number of participants. (Note: if amount is entered here an amount should be entered on line 9022 Group Medical Insurance) Number of Employees Participating During the Data Month: Report the number of employees that were covered under the facility's health insurance plan(s) at the end of this report year during the Data Month.

## Costs and Expenses

Care Related, Support Services, G&A Payroll Taxes, Payroll & Benefits and External Fixed

Line(s) | Remarks
General | "Balance per Books" must be recorded using the following principles: If the account has a debit balance, record as a positive amount If the account has a credit balance, record as a negative amount "Adjustments" may be positive or negative. The "Balance Per Books" column is to match the facility's income statement figures.
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: Change Balance Per Books amounts to reflect actual expenses incurred such as eliminating profit on related-party transactions; Change Balance Per Books amounts to reduce costs to recognize charges, fees, grants, and gifts; Exclude items not recognized by Medicare such as the cost of telephones in resident rooms, contributions made, amounts donated to others, cost of political lobbying, personal expenses of owners or employees, costs related to fund raising events, salaries and associated costs of facility marketing, expenses related to changes of ownership of the facility, expenses related to providing special services, and penalties paid to governmental agencies. Items such as these should be separately reported in General and Administrative costs, line 8085, Other General & Administrative Expense, Medicare Non-Allowable in the balance per books column and removed in the adjustments column.
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.
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.

Care Related

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. See the directions above in the Productive Hours section for lines 301-325 for guidance pertaining to the allocation of Universal Worker and other care related workers’ salaries.
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.
6261 | All non-wage related costs of training for direct care are to be recorded on this line. Nursing facility costs covered by this section include any charge for training and/or the cost of the competency evaluation plus necessary textbooks and other required course materials and travel.
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 should be zero.
6220 | "Activity and Social Service Supplies" include beauty shop supplies, television and radio in common areas and pet supplies.
6176 | "Nursing 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.
6290 | Beauty shop rental income is reported here.

Support Services

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.
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.

General & Administrative

8013 | Administrative salaries include the administrator, assistant administrator, accounting, data processing, clerical, receptionist, security staff and bonuses.
8048 | Record the cost of professional liability insurance only. Property insurance expense is to be reported separately on line 8049 in the External Fixed section of this report. Automobile insurance is to be reported on line 8080.
| CLASSIFICATION OF INSURANCE COSTS
EXPENSE | COST CATEGORY | ACCOUNT NUMBER
Administrative Prof. Liability | G & A | 8048
Automobile | G & A | 8080
Board of Directors | G & A | 8080
Building | External Fixed | 8049
Building Contents | External Fixed | 8049
Business Income | G & A | 8080
Crime Coverage | G & A | 8080
Dental (Group) | Fringe Benefits | 9025
Disability | Fringe Benefits | 9080
Extra Expense | G & A | 8080
Flood | External Fixed | 8049
General Liability | G & A | 8080
Inland Marine | External Fixed | 8049
Loss of Earnings | G & A | 8080
Life (Group) | Fringe Benefits | 9080
Medical (Group) | Fringe Benefits | 9022
MN Fire Surcharge | External Fixed | 8049
Mortgage | Interest Expense | 7031
Property of Others | G & A | 8080
Umbrella | G & A | 8080
Workers Comp | Fringe Benefits | 9024
Other | G & A | 8080
8052 | Record the costs of bad debt on this line. The amount reported in the "Balance Per Books" column should tie to your reporting year trial balance. Any bad debt collected from Medicare during the report year should be entered as an adjustment in the adjustment column. The amount reported in the "Nursing Facility Related Costs" column most likely will NOT tie to your trial balance. Unpaid claims denied by Medicaid and Medicaid claims that have been written off are not allowable. Bad debt that is non-allowable per Medicare guidelines and/or has been disallowed by the Medicare Administrative Contractor (formerly Fiscal Intermediary) is not allowable. Do not include the costs of bad debt collection expense on this line. Bad debt collection expense should be reported on line 8080.
8073 | Record central office costs and management fees directly related to the operation of the nursing facility on this line. The fiscal year central office allocation may be recorded if the fiscal year end is different than the reporting year end. Central office costs should be allocated to the nursing facility according to Medicare cost reporting principles. See MN Statutes, Section 256B.432.
8080 | Other general and administrative expenses include; office supplies, postage, subscriptions, membership dues, including The Joint Commission (formerly JCAHO) costs, local and out of state travel, employment & facility advertising, other insurance, telephone charges, bad debt collection expense, training costs other than the amounts allowed in care related, consultants, purchased services, Bond Administration fees, and non-restricted interest income. (Note: bad debt expense is to be reported on line 8052.) It also includes dietary training and seminars and business meetings, cost report preparation, information technology, Web site, certified audit and data processing fees, automobile insurance, loss of earnings insurance, and the revisit survey fees.
8085 | Items not recognized by Medicare such as the cost of telephones in resident rooms, contributions made, amounts donated to others, cost of political lobbying, personal expenses of owners or employees, costs related to fund raising events, expenses related to changes of ownership of the facility, expenses related to providing special services, and penalties paid to governmental agencies should be separately reported on this line. The amount reported on this line should be removed from allowable nursing home costs by entering a negative amount in the adjustments column.

Payroll Taxes

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.
9021- 9025 | Expenses from a self-insurance fund should be reported in accordance with GAAP, estimated self-insured insurance claims includes estimates of the undiscounted ultimate costs for both reported claims and claims incurred but not reported. Costs reported include amounts reserved for future claims and any reversals of claims made in a prior period.
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.
9025 | Report the employer portion of the dental insurance expense for the reporting period.
9080 | "Other Employee Benefits" includes IRAs, day care, disability insurance, and in-kind benefits. Expenses reported here must not be reported on lines 9210 to 9280.

Payroll Taxes and Fringe Benefits

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.
9100 | The total amount reported as Nursing Facility Related Costs on Line 9100 plus the amount reported as Nursing Facility Related Costs on Line 9200 must equal the amount reported as Nursing Facility Related Costs on Line 9000 less the amount reported on line 9080.

External Fixed

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 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. Transportation, parking, child daycare, and computers are non-allowable. 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 For facilities that operate on an accrual basis, scholarships awarded and entered into financial records by 9/30/2014 and paid by 10/31/2014 are considered to be within this reporting period. 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.
8049 | Report the cost of Property Insurance (on Building & Building Contents) only on this line. Property insurance must be reduced to reflect the amounts related to non-reimbursable areas. Professional liability insurance is to be reported on line 8048. Automobile insurance is to be reported on line 8080.
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.
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.

Total Operating Expense

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.

Revenue

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.
Description of Revenue | Where to record on cost report
Private room differential for a Medicaid resident when MA is paying for the private room differential | MA, line 9410
Medicaid gross adjustments | MA, line 9410
Payment for Medicaid resident by MA for Bed Hold day(s) | MA, line 9410
Private room differential for a Medicaid resident when the private room differential is paid by resident or Guarantor | PP, line 9420
Spend-down for Medicaid resident when spend-down is paid by resident | MA, line 9410
Medicare co-insurance that resident or Guarantor pays for | MC, line 9430
Payment for Medicaid resident by Guarantor or family member for Bed Hold | PP, line 9420
Contractual adjustments for Medicare | MC, line 9430
Medicare co-insurance bad debt for dual eligibles | MC, line 9430
Hospice | Other, line 9440
Medicare cost report settlements for prior year(s) | put to prior year, not on cost report
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.
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.
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.

Square Footage

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.

Current Assets

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, 2014. 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.

Debt

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. Date of Loan: Enter the date the loan agreement was signed. Type of Loan: Enter the code below which most closely corresponds to the type of loan listed. (Code).(Type of Capital Asset Associated with the Loan) Land Building and Building Improvements Attached Fixtures Land Improvements Depreciable Equipment (other than vehicle) Vehicles All the above items Codes 11,12, and 13 Codes 11,12, 13, and 14 Construction in Progress (CIP) Length of Loan (in months): The length of the loan must be recorded in months (i.e., 25 years should be recorded as 300), report demand notes with a length of zero months. The length of the loan is the original term, not the remaining term of the debt. Amount Originally Borrowed: Enter the original principal borrowed. Effective Interest Rate (%): The effective interest rate including the effective points, financing charges, and amortization of bond premium or discount must be recorded for each loan. For those loans which have variable or adjustable rates, the effective interest rate is determined by dividing the interest expense including points, financing charges, and amortization of bond premium or discount for the reporting year by the average allowable debt. Interest rates are to be entered as whole numbers as opposed to decimals. For example, 4% is entered as 4 not .04. Interest Expense this Reporting Year: Interest expense includes actual interest payments made during the reporting year plus the amortization of any financing charges and/or amortization of bond premium or discount. Interest Income from Bond Reserve Funds: Record interest income from bond reserve funds. Principal Balance Beginning This Year: Loans taken out during the reporting year should show a beginning balance of zero. Principal Payments (this year): Principal payments are the portion of debt service that is not interest or the balance of a loan paid to refinance the debt. For CIP loans report negative principal payment(s) to reflect project draws. Principal Balance Refinanced (this year): If debt was consolidated or refinanced during the reporting year, enter the principal balance on the date the debt was refinanced. Debt Service Payments: Record the periodic payment amount required to be sent to the debt holder according to the agreement between the borrower and lender. It is not the amount actually paid during the year. Frequency of Debt Service Payments: Record how often the Debt Service Payments are to be made according to the agreement between the borrower and lender. If payments are due monthly, enter 12; if quarterly, enter 4; if semi-annually, enter 2; if annually, enter 1. Variable Interest Rate Loan: If the loan has a variable interest rate loan, check "Yes". Restrictions on Refinancing the Loan: If there are restrictions on refinancing the loan, check "Yes".

Leases

| 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 | Type of Lease: Use the code which best describes the nursing facility's lease or rental agreements. (Code).(Type of Capital Asset Leased) Land Building and Building Improvements Attached Fixtures Land Improvements Depreciable Equipment (other than vehicle) Vehicles All the above items Codes 11,12, and 13 Codes 11,12, 13, and 14 Lease Amount: Enter the total cost of the lease or rental agreement over the entire term of the lease. Lease Expense this Reporting Year: Enter the actual payments made under the lease agreement during the reporting year. Beginning and Ending Lease Balances: Enter the amounts remaining to be paid under the lease agreement on these dates. Frequency of Lease Payment: Enter how often the payments are required. If payments are due monthly, enter 12; if quarterly, enter 4; if semi-annually, enter 2: if annually, enter 1.

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)

CALCULATION OF MAXIMUM PAYMENT IN LIEU OF REAL ESTATE TAXES

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
TAX CAPACITY |  | 25,795
Market Value of Facility | 737,000 |
Times Tax Capacity % | x 3.5% |
Tax Capacity | 25,795 |
TAX CAPACITY RATES |  |
Fire Protection | 2.6407 |
Police | 4.8768 |
Sanitation | 15.9093 |
Road Maintenance | 19.4668 |
Total Capacity Rate |  | 42.8936
MAXIMUM PAYMENT IN LIEU OF REAL ESTATE TAXES | 11,064

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.

## NF Employee Scholarship Program

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.
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. 7.67)). Do not enter commas or dollar sign ($).
Average hours worked/week | Enter average number of hours employee worked during the report period or a minimum 3 month time period during the report period (If not using the standard report period, document the time period in your records).
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).
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 four 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).
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).
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.

General Instructions:

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.