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["（別紙１－４－２）"]
["介 護 予 防・日 常 生 活 支 援 総 合 事 業 費 算 定 に 係 る 体 制 等 状 況 一 覧 表"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事 業 所 番 号"]
[]
["提供サービス",null,null,"施設等の区分",null,"人員配置区分",null,"そ　 　　の　 　　他　　 　該　　 　当　　 　す 　　　る 　　　体 　　　制 　　　等",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"LIFEへの登録",null,null,null,"割 引"]
[null,null,null,null,null,null,null,"高齢者虐待防止措置実施の有無","□","１ 減算型",null,null,"□","２ 基準型",null,null,null,null,null,null,null,null,null,null,"□","１　なし",null,null,"□","１　なし"]
[null,null,null,null,null,null,null,"同一建物減算（同一敷地内建物等に居住する者への提供）","□","１ 非該当",null,null,"□","２ 該当",null,null,null,null,null,null,null,null,null,null,"□","２　あり",null,null,"□","２　あり"]
[]
["　","　","　","　","　","　","　","同一建物減算（同一敷地内建物等に居住する者への提供（利用者50人以上））","□","１ 非該当",null,null,"□","２ 該当",null,null,"　","　","　","　",null,null,null,"　","　",null,null,"　","　",null,null,"　"]
["　","　","　","　","　","　","　",null,null,null,null,null,null,null,null,null,null,null,null,null,"　","　","　","　","　",null,null,"　","　",null,null,"　"]
[null,null,null,null,null,null,null,"同一建物減算（同一敷地内建物等に居住する者への提供割合90％以上）","□","１ 非該当",null,null,"□","２ 該当"]
[]
[null,null,null,null,null,null,null,"特別地域加算","□","１ なし",null,"□","２ あり"]
["□","A2","訪問型サービス（独自）",null,null,null,null,"中山間地域等における小規模事業所\n加算（地域に関する状況）","□","１ 非該当",null,null,"□","２ 該当"]
[]
[null,null,null,null,null,null,null,"中山間地域等における小規模事業所\n加算（規模に関する状況）","□","１ 非該当",null,null,"□","２ 該当"]
[]
[null,null,null,null,null,null,null,"口腔連携強化加算口腔連携強化加算","□","１ なし",null,"□","２ あり"]
[null,null,null,null,null,null,null,"介護職員等処遇改善加算介護職員等処遇改善加算","□","１ なし",null,null,null,null,null,null,null,null,null,null,"□","７ 加算Ⅰ"]
[null,null,null,null,null,null,null,null,"□","８ 加算Ⅱ８ 加算Ⅱ",null,null,"□","９ 加算Ⅲ",null,null,"□","Ａ 加算Ⅳ",null,null,"□","Ｂ 加算Ⅴ(１)"]
[null,null,null,null,null,null,null,null,"□","Ｃ 加算Ⅴ(２)",null,null,"□","Ｄ 加算Ⅴ(３)",null,null,"□","Ｅ 加算Ⅴ(４)",null,null,"□","Ｆ 加算Ⅴ(５)"]
[null,null,null,null,null,null,null,null,"□","Ｇ 加算Ⅴ(６)",null,null,"□","Ｈ 加算Ⅴ(７)",null,null,"□","Ｊ 加算Ⅴ(８)",null,null,"□","Ｋ 加算Ⅴ(９)"]
[null,null,null,null,null,null,null,null,"□","Ｌ 加算Ⅴ(１０)",null,null,"□","Ｍ 加算Ⅴ(１１)",null,null,"□","Ｎ 加算Ⅴ(１２)",null,null,"□","Ｐ 加算Ⅴ(１３)"]
[null,null,null,null,null,null,null,null,"□","Ｒ 加算Ⅴ(１４)"]
[null,null,null,null,null,null,null,"職員の欠員による減算の状況","□","１ なし",null,null,"□","２ 看護職員２ 看護職員",null,null,"□","３ 介護職員３ 介護職員",null,null,null,null,null,null,"□","１　なし",null,null,"□","１　なし"]
[null,null,null,null,null,null,null,"高齢者虐待防止措置実施の有無","□","１ 減算型",null,null,"□","２ 基準型",null,null,null,null,null,null,null,null,null,null,"□","２　あり",null,null,"□","２　あり"]
[null,null,null,null,null,null,null,"業務継続計画策定の有無","□","１ 減算型",null,null,"□","２ 基準型"]
[null,null,null,null,null,null,null,"若年性認知症利用者受入加算若年性認知症利用者受入加算","□","１ なし",null,"□","２ あり"]
[null,null,null,null,null,null,null,"生活機能向上グループ活動加算生活機能向上グループ活動加算","□","１ なし",null,"□","２ あり"]
[null,null,null,null,null,null,null,"栄養アセスメント・栄養改善体制","□","１ なし",null,"□","２ あり"]
["□","A6","通所型サービス（独自）通所型サービス（独自）",null,null,null,null,"口腔機能向上加算口腔機能向上加算","□","１ なし",null,"□","２ あり"]
[null,null,null,null,null,null,null,"一体的サービス提供加算一体的サービス提供加算","□","１ なし",null,"□","２ あり"]
[null,null,null,null,null,null,null,"サービス提供体制強化加算サービス提供体制強化加算","□","１ なし",null,"□","５ 加算Ⅰ",null,"□","４ 加算Ⅱ",null,"□","６ 加算Ⅲ"]
[null,null,null,null,null,null,null,"生活機能向上連携加算","□","１ なし",null,"□","３ 加算Ⅰ",null,"□","２ 加算Ⅱ"]
[null,null,null,null,null,null,null,"科学的介護推進体制加算","□","１ なし",null,"□","２ あり"]
[null,null,null,null,null,null,null,"介護職員等処遇改善加算","□","１ なし",null,null,null,null,null,null,null,null,null,null,"□","７ 加算Ⅰ"]
[null,null,null,null,null,null,null,null,"□","８ 加算Ⅱ",null,null,"□","９ 加算Ⅲ",null,null,"□","Ａ 加算Ⅳ",null,null,"□","Ｂ 加算Ⅴ(１)"]
[null,null,null,null,null,null,null,null,"□","Ｃ 加算Ⅴ(２)",null,null,"□","Ｄ 加算Ⅴ(３)",null,null,"□","Ｅ 加算Ⅴ(４)",null,null,"□","Ｆ 加算Ⅴ(５)"]
[null,null,null,null,null,null,null,null,"□","Ｇ 加算Ⅴ(６)",null,null,"□","Ｈ 加算Ⅴ(７)",null,null,"□","Ｊ 加算Ⅴ(８)",null,null,"□","Ｋ 加算Ⅴ(９)"]
[null,null,null,null,null,null,null,null,"□","Ｌ 加算Ⅴ(１０)",null,null,"□","Ｍ 加算Ⅴ(１１)",null,null,"□","Ｎ 加算Ⅴ(１２)",null,null,"□","Ｐ 加算Ⅴ(１３)"]
[null,null,null,null,null,null,null,null,"□","Ｒ 加算Ⅴ(１４)"]
[null,null,"備考　１ 「割引｣を｢あり｣と記載する場合は「介護予防・日常生活支援総合事業者による事業費の割引に係る割引率の設定について」（別紙37）を添付してください。"]
[null,null,"　　　２ 「サービス提供体制強化加算」については、「サービス提供体制強化加算に関する届出書」（別紙38）を添付してください。"]
[]
[]
[]
["介 護 予 防・日 常 生 活 支 援 総 合 事 業 費 算 定 に 係 る 体 制 等 状 況 一 覧 表（主たる事業所の所在地以外の場所で一部実施する場合の出張所等の状況）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事 業 所 番 号"]
[]
["提供サービス",null,null,"施設等の区分",null,"人員配置区分",null,"そ　 　　の　 　　他　　 　該　　 　当　　 　す 　　　る 　　　体 　　　制 　　　等"]
[null,null,null,null,null,null,null,"高齢者虐待防止措置実施の有無","□","１ 減算型",null,null,"□","２ 基準型"]
[null,null,null,null,null,null,null,"同一建物減算（同一敷地内建物等に居住する者への提供）","□","１ 非該当",null,null,"□","２ 該当"]
[]
["　","　","　","　","　","　","　","同一建物減算（同一敷地内建物等に居住する者への提供（利用者50人以上））","□","１ 非該当",null,null,"□","２ 該当",null,null,"　","　","　","　",null,null,null,null,"　",null,null,null,null,null,null,"　"]
["　","　","　","　","　","　","　",null,null,null,null,null,null,null,null,null,null,null,null,null,"　","　","　","　","　","　","　","　","　","　","　","　"]
[null,null,null,null,null,null,null,"同一建物減算（同一敷地内建物等に居住する者への提供割合90％以上）","□","１ 非該当",null,null,"□","２ 該当"]
[]
["□","A2","訪問型サービス（独自）",null,null,null,null,"特別地域加算","□","１ なし",null,"□","２ あり"]
[null,null,null,null,null,null,null,"中山間地域等における小規模事業所\n加算（地域に関する状況）","□","１　非該当",null,null,"□","２　該当"]
[]
[null,null,null,null,null,null,null,"中山間地域等における小規模事業所\n加算（規模に関する状況）","□","１　非該当",null,null,"□","２　該当"]
[]
[null,null,null,null,null,null,null,"口腔連携強化加算","□","１ なし",null,"□","２ あり"]
[null,null,null,null,null,null,null,"職員の欠員による減算の状況","□","１ なし",null,null,"□","２ 看護職員",null,null,"□","３ 介護職員"]
[null,null,null,null,null,null,null,"高齢者虐待防止措置実施の有無","□","１ 減算型",null,null,"□","２ 基準型"]
[null,null,null,null,null,null,null,"業務継続計画策定の有無","□","１ 減算型",null,null,"□","２ 基準型"]
[null,null,null,null,null,null,null,"若年性認知症利用者受入加算","□","１ なし",null,"□","２ あり"]
[null,null,null,null,null,null,null,"生活機能向上グループ活動加算","□","１ なし",null,"□","２ あり"]
["□","A6","通所型サービス（独自）",null,null,null,null,"栄養アセスメント・栄養改善体制","□","１ なし",null,"□","２ あり"]
[null,null,null,null,null,null,null,"口腔機能向上加算","□","１ なし",null,"□","２ あり"]
[null,null,null,null,null,null,null,"生活機能向上連携加算","□","１ なし",null,"□","３ 加算Ⅰ",null,"□","２ 加算Ⅱ"]
[null,null,null,null,null,null,null,"科学的介護推進体制加算","□","１ なし",null,"□","２ あり"]
[]
[null,null,"備考　１　この表は、事業所所在地以外の場所で一部事業を実施する出張所等がある場合について記載することとし、複数出張所等を有する場合は出張所ごとに提出してください。"]