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["様式第１号"]
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["保険医療機関コード等"]
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["様式第２号"]
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["様式1-2"]
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["（表）"]
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[]
["単位別（単位目）","従業者","区　　　　　分",{"$nulls":5},"生活相談員",{"$nulls":5},"看護職員",{"$nulls":5},"介護職員",{"$nulls":5},"機能訓練指導員"]
[{"$nulls":8},"専従",null,null,"兼務",null,null,"専従",null,null,"兼務",null,null,"専従",null,null,"兼務",null,null,"専従",null,null,"兼務"]
[null,null,"常　　　勤",null,null,null,"（人）"]
[null,null,"非　常　勤",null,null,null,"（人）"]
[null,null,"※基準上の必要人数",null,null,null,"（人）"]
[null,null,"※適合の可否"]
[null,"食堂及び機能訓練室の面積",{"$nulls":13},"㎡",null,"※基準上の必要面積",{"$nulls":8},"※適合の可否"]
[{"$nulls":23},"㎡以上"]
[null,"主な掲示事項","利用定員",{"$nulls":9},"人"]
[null,null,"営業日 ",{"$nulls":4},"日","月","火","水","木","金","土","祝","その他年間\nの休日　　"]
[]
[null,null,"営業時間 ",{"$nulls":4},"平日",{"$nulls":4},"～",null,null,"土曜",{"$nulls":4},"～",null,null,"日曜日・祝日",{"$nulls":5},"～"]
[{"$nulls":7},"備考"]
[null,null,"利用料 ",{"$nulls":4},"法定代理受領分",{"$nulls":5},"青木村が定める基準額の利用者負担分"]
[{"$nulls":7},"法定代理受領分以外",{"$nulls":5},"青木村が定める基準額"]
[null,null,"その他の費用"]
[null,null,"通常の事業の\n実施地域",{"$nulls":4},"①",{"$nulls":4},"②",{"$nulls":4},"③",{"$nulls":4},"④",{"$nulls":4},"⑤"]
[{"$nulls":7},"備考"]
["注　※欄は記入しないこと。"]
[]
[]
["（裏）"]
["単位別（単位目）","従業者","区　　　　　分",{"$nulls":5},"生活相談員",{"$nulls":5},"看護職員",{"$nulls":5},"介護職員",{"$nulls":5},"機能訓練指導員"]
[{"$nulls":8},"専従",null,null,"兼務",null,null,"専従",null,null,"兼務",null,null,"専従",null,null,"兼務",null,null,"専従",null,null,"兼務"]
[null,null,"常　　　勤",null,null,null,"（人）"]
[null,null,"非　常　勤",null,null,null,"（人）"]
[null,null,"※基準上の必要人数",null,null,null,"（人）"]
[null,null,"※適合の可否"]
[null,"食堂及び機能訓練室の面積",{"$nulls":13},"㎡",null,"※基準上の必要面積",{"$nulls":8},"※適合の可否"]
[{"$nulls":23},"㎡以上"]
[null,"主な掲示事項","利用定員",{"$nulls":9},"人"]
[null,null,"営業日 ",{"$nulls":4},"日","月","火","水","木","金","土","祝","その他年間\nの休日　　"]
[]
[null,null,"営業時間 ",{"$nulls":4},"平日",{"$nulls":4},"～",null,null,"土曜",{"$nulls":4},"～",null,null,"日曜日・祝日",{"$nulls":5},"～"]
[{"$nulls":7},"備考"]
[null,null,"利用料 ",{"$nulls":4},"法定代理受領分"]
[{"$nulls":7},"法定代理受領分以外"]
[null,null,"その他の費用"]
[null,null,"通常の事業の\n実施地域",{"$nulls":4},"①",{"$nulls":4},"②",{"$nulls":4},"③",{"$nulls":4},"④",{"$nulls":4},"⑤"]
[{"$nulls":7},"備考"]
["注　単位数が２単位以上の場合に記載すること。"]
[]
["事業の一部を行う施設の数",{"$nulls":14},"施設"]
["事業の一部を行う施設","（フリガナ）"]
[null,"名　称"]
[{"$nulls":5},"（郵便番号　",{"$nulls":6},"－",{"$nulls":4},"）"]
[null,"（フリガナ）"]
[null,"所在地",{"$nulls":4},"長野県",{"$nulls":8},"市","郡"]
[]
[null,"連絡先",null,null,null,"電話番号",{"$nulls":12},"ＦＡＸ番号"]
[null,"備　考"]
["注　事業所の所在地以外の場所に事業の一部を行う施設を有する場合に記入すること。"]

{"sheet":"No6.設備項目一覧","index":3,"n_rows":10,"n_cols":36,"rows_kept":10,"cut":false,"hidden":false,"merged":[[3,10,3,39],[12,0,12,39],[8,35,8,39],[3,0,3,9],[5,35,5,39],[5,10,5,34],[5,0,5,9],[1,0,1,39],[9,0,9,39],[6,35,6,39],[6,10,6,34],[8,10,8,34],[6,0,6,9],[8,0,8,9],[7,0,7,9],[7,10,7,34],[7,35,7,39]],"flags":["formulas_cached_only"]}
["参考様式５"]
["事業所の設備等に係る項目一覧表"]
[]
["事業所名"]
[]
["部屋・設備の種類",{"$nulls":9},"設備基準上適合すべき項目についての実態",{"$nulls":24},"※適合の可否\n（村処理欄）"]
["サービス提供上配慮\nすべき設備の概要\n"]
["非常災害設備等"]
["備品の目録",{"$nulls":9},"備品の品名及び数量"]
["※各部屋の面積、手洗い・トイレの状況、非常用災害設備等の状況を記載してください。"]

{"sheet":"No7.管理者経歴書 ","index":4,"n_rows":20,"n_cols":7,"rows_kept":20,"cut":false,"hidden":false,"merged":[[0,0,0,6],[13,4,13,5],[19,0,19,2],[19,3,19,6],[1,0,1,6],[2,1,2,6],[6,4,6,5],[7,4,7,5],[7,1,7,3],[6,1,6,3],[20,0,20,6],[14,4,14,5],[15,4,15,5],[16,0,16,2],[4,0,15,0],[17,0,17,2],[18,0,18,6],[17,3,17,6],[4,4,4,5],[5,4,5,5],[3,1,3,4],[11,1,11,3],[11,4,11,5],[12,1,12,3],[12,4,12,5],[4,1,4,3],[8,4,8,5],[9,4,9,5],[5,1,5,3],[8,1,8,3],[10,4,10,5],[9,1,9,3],[15,1,15,3],[14,1,14,3],[10,1,10,3],[13,1,13,3]],"flags":["formulas_cached_only"]}
["参考様式１"]
["管理者 経歴書"]
["住所"]
["氏名",{"$nulls":4},"生年月日"]
["経　　　　　　　　　歴","期   間",null,null,"勤 務 先",null,"職務内容等"]
{"$rows_empty":11}
["資　格　の　種　類",null,null,"種類",null,"取得年月日"]
["管理する事業所又は施設"]
[]
["　　備　　　　　　　　考　　"]

{"sheet":"No10.苦情処理の措置概要","index":5,"n_rows":12,"n_cols":1,"rows_kept":12,"cut":false,"hidden":false,"merged":[[8,0,8,6],[9,0,9,6],[12,0,12,6],[10,0,10,6],[11,0,11,6],[14,0,14,6],[0,0,0,6],[2,0,2,6],[4,1,4,6],[6,0,6,6],[7,0,7,6]],"flags":["formulas_cached_only"]}
["参考様式３"]
[]
["利用者からの苦情を処理するために講ずる措置の概要"]
[]
["事業所又は施設の名称"]
[]
["　措置の概要"]
["１　利用者からの相談又は苦情などに対応する常設の窓口（連絡先）及び担当者の設置状況"]
[]
["２　円滑かつ迅速に苦情処理を行うための処理体制及び手順"]
[]
["３　その他参考事項"]

{"sheet":"No11.勤務形態一覧（通所型）","index":6,"n_rows":27,"n_cols":46,"rows_kept":27,"cut":false,"hidden":false,"merged":[[11,45,11,52],[12,45,12,52],[21,45,21,52],[18,8,18,13],[18,45,18,52],[17,45,17,52],[19,45,19,52],[20,45,20,52],[13,45,13,52],[21,1,21,5],[21,6,21,7],[18,1,18,5],[18,6,18,7],[20,6,20,7],[19,1,19,5],[19,6,19,7],[15,1,15,5],[14,45,14,52],[15,45,15,52],[15,6,15,7],[14,8,14,13],[14,6,14,7],[16,6,16,7],[16,45,16,52],[22,1,22,52],[15,8,15,13],[16,8,16,13],[17,8,17,13],[19,8,19,13],[20,8,20,13],[16,1,16,5],[20,1,20,5],[17,1,17,5],[17,6,17,7],[8,2,8,3],[8,8,8,9],[12,1,12,5],[14,1,14,5],[8,6,8,7],[12,8,12,13],[9,1,10,5],[9,6,10,7],[9,45,10,52],[6,14,6,15],[6,19,6,20],[8,10,8,11],[6,17,6,18],[8,15,8,16],[6,22,6,52],[6,11,6,12],[6,1,6,10],[8,4,8,5],[9,8,10,11],[10,12,10,13],[21,8,21,13],[13,1,13,5],[13,6,13,7],[13,8,13,13],[11,1,11,5],[11,6,11,7],[12,6,12,7],[11,8,11,13],[26,1,26,35],[23,43,23,52],[23,36,23,42],[24,36,26,42],[24,43,24,52],[26,43,26,52],[25,43,25,52],[23,1,23,35],[24,1,24,35],[25,1,25,35],[5,1,5,7],[5,8,5,12],[5,14,5,21],[0,1,0,52],[1,1,1,52],[3,1,3,7],[4,1,4,7],[3,8,3,34],[4,8,4,34]],"flags":["formulas_cached_only"]}
[null,"参考様式4－2 【通所型用】 "]
[null,"従業者の勤務の体制及び勤務形態一覧表"]
[]
[null,"事業所名"]
[null,"サービスの種類"]
[null,"利用定員",{"$nulls":11},"人"]
[null,"サービス提供時間帯",{"$nulls":11},"～",null,null,"（",null,null,"時間",null,"）","※利用者を施設に迎えてから送り出すまでの時間（送迎時間を除く。）"]
[]
[null,"（",{"$nulls":4},"年",null,null,null,"月分",null,"）",null,"（",null,null,"単位目",null,null,"）"]
[null,"職種",{"$nulls":4},"勤務\n形態",null,"氏名",{"$nulls":5},1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,"備　考"]
[{"$nulls":12},"曜日"]
{"$rows_empty":10}
[null,"合計"]
[null,"注１：　｢勤務形態｣欄は、常勤・専従の場合は｢Ａ｣、常勤・兼務の場合は｢Ｂ｣、非常勤・専従の場合は｢Ｃ｣、非常勤・兼務の場合は｢D｣と記入すること。"]
[null,"注２：　１月間の勤務時間数を記入すること。公休の場合は｢×｣を記入すること。",{"$nulls":34},"担当者名",{"$nulls":6},"担当者連絡先"]
[null,"注３：　職種ごとに分けて記載すること。"]
[null,"注４：　実施単位ごとに作成すること。",{"$nulls":41},"TEL"]
[{"$nulls":43},"FAX"]

{"sheet":"No13.給付費算定届出書","index":7,"n_rows":55,"n_cols":37,"rows_kept":55,"cut":false,"hidden":false,"merged":[[16,1,18,8],[30,1,32,8],[19,0,32,0],[25,13,25,14],[25,16,25,17],[21,19,21,36],[16,19,16,36],[30,9,30,12],[30,13,30,14],[30,16,30,17],[19,9,19,36],[37,32,37,36],[38,32,38,36],[10,16,10,17],[16,9,16,12],[16,13,16,14],[16,16,16,17],[21,9,21,12],[21,13,21,14],[37,2,37,13],[39,0,39,9],[37,16,37,20],[38,16,38,20],[37,14,37,15],[38,14,38,15],[30,19,30,36],[38,21,38,22],[37,27,37,31],[38,27,38,31],[38,25,38,26],[38,2,38,13],[13,13,13,22],[13,27,13,36],[14,9,14,22],[27,9,27,36],[25,9,25,12],[15,27,15,36],[17,9,17,36],[18,9,18,36],[23,9,23,36],[42,0,42,5],[42,6,42,36],[35,16,35,20],[36,16,36,20],[35,14,35,15],[7,30,7,36],[7,21,7,29],[20,9,20,36],[15,13,15,22],[35,32,35,36],[9,9,9,36],[8,9,8,36],[24,9,24,12],[24,23,24,26],[25,1,27,8],[28,9,28,12],[21,16,21,17],[14,27,14,36],[10,9,10,12],[10,13,10,14],[11,9,11,36],[36,32,36,36],[21,1,23,8],[28,13,28,22],[28,27,28,36],[24,27,24,36],[24,13,24,22],[32,9,32,36],[15,23,15,26],[28,23,28,26],[38,23,38,24],[33,32,34,36],[35,21,35,22],[35,23,35,24],[35,25,35,26],[36,21,36,22],[33,27,34,31],[36,23,36,24],[35,27,35,31],[36,27,36,31],[40,0,41,0],[39,20,39,36],[36,25,36,26],[37,21,37,22],[37,23,37,24],[37,25,37,26],[41,1,41,18],[41,19,41,36],[36,14,36,15],[33,0,38,0],[33,1,34,13],[33,14,34,15],[33,16,34,20],[33,21,34,26],[35,2,35,13],[29,9,29,36],[31,9,31,36],[15,1,15,8],[26,9,26,36],[1,0,1,36],[0,0,0,2],[36,2,36,13],[8,0,18,0],[13,9,13,12],[13,23,13,26],[14,23,14,26],[15,9,15,12],[19,1,19,8],[20,1,20,8],[24,1,24,8],[28,1,28,8],[29,1,29,8],[8,1,8,8],[9,1,9,8],[10,1,12,8],[13,1,13,8],[14,1,14,8]],"flags":["formulas_cached_only"]}
["様式２"]
["介護予防・日常生活支援総合事業費算定に係る体制等に関する届出書"]
[{"$nulls":36},"　　年　　月　　日　"]
["　（宛先）青木村長"]
[{"$nulls":18},"所在地（住所）"]
[{"$nulls":18},"名称（氏名）",{"$nulls":16},"㊞"]
[]
["　このことについて、関係書類を添えて以下のとおり届け出ます。",{"$nulls":20},"事業所所在地市町村番号"]
["届　出　者","フリガナ"]
[null,"名　　称"]
[null,"主たる事務所の所在地",{"$nulls":7},"（郵便番号",{"$nulls":5},"-",null,null,"）"]
[]
[{"$nulls":9},"（ビルの名称等）"]
[null,"連 絡 先",{"$nulls":7},"電話番号",{"$nulls":13},"ＦＡＸ番号"]
[null,"法人の種別",{"$nulls":21},"法人所轄庁"]
[null,"代表者の職・氏名",{"$nulls":7},"職名",{"$nulls":13},"氏名"]
[null,"代表者の住所",{"$nulls":7},"（郵便番号",{"$nulls":5},"-",null,null,"）"]
[]
[]
["事業所・施設の状況","フリガナ"]
[null,"名　　称"]
[null,"主たる事業所・施設の\n所在地",{"$nulls":7},"（郵便番号",{"$nulls":5},"-",null,null,"）"]
[]
[]
[null,"連 絡 先",{"$nulls":7},"電話番号",{"$nulls":13},"ＦＡＸ番号"]
[null,"主たる事業所の所在地以外\nの場所で一部実施する場合\nの出張所等の所在地",{"$nulls":7},"（郵便番号",{"$nulls":5},"-",null,null,"）"]
[]
[]
[null,"連 絡 先",{"$nulls":7},"電話番号",{"$nulls":13},"ＦＡＸ番号"]
[null,"管理者の氏名"]
[null,"管理者の住所",{"$nulls":7},"（郵便番号",{"$nulls":5},"-",null,null,"）"]
[]
[]
["届出を行う事業所の状況","同一所在地において行う事業等の種類",{"$nulls":12},"実施\n事業",null,"指定年月日",{"$nulls":4},"異動等の区分",{"$nulls":5},"異動（予定）\n年月日",{"$nulls":4},"異動項目\n（※変更の場合）"]
[]
[null,null," 訪問介護相当サービス\n※現行相当サービス",{"$nulls":18},"1新規",null,"2変更",null,"3終了"]
[null,null," 訪問型サービスＡ\n※緩和した基準によるサービス",{"$nulls":18},"1新規",null,"2変更",null,"3終了"]
[null,null," 通所介護相当サービス\n※現行相当サービス",{"$nulls":18},"1新規",null,"2変更",null,"3終了"]
[null,null," 通所型サービスＡ\n※緩和した基準によるサービス",{"$nulls":18},"1新規",null,"2変更",null,"3終了"]
["介護保険事業所番号",{"$nulls":19},"（既に指定（許可）を受けている場合・・・複数ある場合は適宜様式を補正して記入）"]
["特記事項","変　更　前",{"$nulls":17},"変　更　後"]
[]
["関係書類"]
[]
[null,"備考1","　「事業所所在地市町村番号」は記載の必要はありません。"]
[null,2,"　「法人の種別」欄は、申請者が法人である場合に、「社会福祉法人」、「医療法人」、「社団法人」、"]
[null,null,"「財団法人」、「株式会社」、「有限会社」等の別を記入してください。"]
[null,3,"　「法人所轄庁」欄は、申請者が認可法人である場合に、その主務官庁の名称を記載してください。"]
[null,4,"　「実施事業」欄は、該当する欄に「○」を記入してください。"]
[null,5,"　「異動等の区分」欄は、今回届出を行う事業所について該当する数字に「○」を記入してください。"]
[null,6,"　「異動項目」欄には、様式3「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」に掲げる"]
[null,null,"項目を記載してください。"]
[null,7,"　「特記事項」欄には、異動の状況について具体的に記載してください。"]
[null,8,"　「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所在地」について、複数の出張所等を"]
[null,null,"有する場合は、適宜欄を補正して、全ての出張所等の状況について記載してください。"]

{"sheet":"No14.給付費に係る体制等状況一覧","index":8,"n_rows":46,"n_cols":21,"rows_kept":46,"cut":false,"hidden":false,"merged":[[45,4,45,13],[45,14,45,18],[41,4,41,13],[41,14,41,18],[42,4,42,13],[42,14,42,18],[43,4,44,13],[43,14,43,18],[44,14,44,18],[38,4,38,13],[38,14,38,18],[39,4,39,13],[39,14,39,18],[40,4,40,13],[40,14,40,18],[31,2,45,2],[31,3,45,3],[31,4,31,13],[31,14,31,18],[32,4,32,13],[32,14,32,18],[33,4,33,13],[33,14,33,18],[34,4,34,13],[34,14,34,18],[27,4,27,13],[27,14,27,18],[28,4,29,13],[28,14,28,18],[29,14,29,18],[30,4,30,13],[30,14,30,18],[22,2,22,13],[23,2,24,3],[23,4,23,20],[24,4,24,18],[25,2,30,2],[25,3,30,3],[25,4,25,13],[25,14,25,18],[26,4,26,13],[26,14,26,18],[18,2,18,3],[18,16,18,20],[19,2,19,16],[19,17,19,20],[20,2,20,16],[20,17,20,20],[14,9,14,14],[16,2,16,3],[16,4,16,14],[16,15,16,20],[17,2,17,3],[17,4,17,14],[17,15,17,17],[17,18,17,20],[2,2,2,4],[2,17,2,20],[3,3,3,19],[6,11,6,14],[8,11,8,14],[9,10,9,11],[37,4,37,13],[36,4,36,13],[36,14,36,18],[37,14,37,18],[35,4,35,13],[35,14,35,18],[11,12,12,14]],"flags":["formulas_cached_only"]}
[]
[]
[null,null,"様式３",{"$nulls":14},"年　　　　　　月　　　　　　日"]
[null,null,null,"介護予防・日常生活支援総合事業費算定に係る体制等状況一覧表"]
[]
[]
[{"$nulls":11},"　　住　　　　　　　　所"]
[]
[{"$nulls":11},"　　氏　　　　　　　　名",{"$nulls":8},"　印"]
[{"$nulls":10},"届出者"]
[]
[{"$nulls":12},"法人にあっては、名称　　　　　　　　　　　及び代表者の職･氏名"]
[]
[]
[{"$nulls":9},"届出担当者　連絡先（電話番号)"]
[]
[null,null,"サービス種類",{"$nulls":12},"新　規　・　変　更　の　別"]
[null,null,"事業所名",{"$nulls":12},"1　　　新規",null,null,"　2　　　　変更"]
[null,null,"事業所番号",{"$nulls":12},"平成　　令和","　　　年　　　　　月　　　　日から適用"]
[null,null,"社会福祉法人軽減事業実施の有無",{"$nulls":14},"　　1　　なし　　　　　2　　あり"]
[null,null,"ＬＩＦＥへの登録",{"$nulls":14},"　　1　　なし　　　　　2　　あり"]
[]
[null,null,"次の区分に該当するものとして届け出ます。"]
[null,null,"提供サービス",null,"届　　　　出　　　　の　　　　内　　　　容"]
[{"$nulls":4},"そ　の　他　該　当　す　る　体　制　等",{"$nulls":14},"変更","割　引"]
[null,null,"Ａ２","訪問介護相当サービス　※現行相当サービス","特別地域加算",{"$nulls":9},"　1　なし　　　2　あり",{"$nulls":5},"　1　　なし"]
[{"$nulls":4},"中山間地域における小規模事業所加算　　　　　　　(地域に関する状況)",{"$nulls":9},"　1　非該当　2　該当",{"$nulls":5},"　2　　あり"]
[{"$nulls":4},"中山間地域における小規模事業所加算　　　　　　　(規模に関する状況)",{"$nulls":9},"　1　非該当　2　該当"]
[{"$nulls":4},"介護職員処遇改善加算",{"$nulls":9},"　1　なし　　　 6　加算Ⅰ   　5加算Ⅱ　  　2　加算Ⅲ"]
[{"$nulls":14},"　3　加算Ⅳ　 　4　加算Ⅴ"]
[{"$nulls":4},"介護職員等特定処遇改善加算",{"$nulls":9},"　1　なし　　　2　加算Ⅰ　　　3　加算Ⅱ　　　　"]
[null,null,"Ａ６","通所介護相当サービス　※現行相当サービス","職員の欠員による減算の状況",{"$nulls":9},"　1　なし　  　2　看護職員   　3　介護職員",{"$nulls":5},"　1　　なし"]
[{"$nulls":4},"若年性認知症利用者受入加算",{"$nulls":9},"　1　なし　　　2　あり",{"$nulls":5},"　2　　あり"]
[{"$nulls":4},"生活機能向上グループ活動加算",{"$nulls":9},"　1　なし　　　2　あり"]
[{"$nulls":4},"運動器機能向上体制",{"$nulls":9},"　1　なし　　　2　あり"]
[{"$nulls":4},"栄養アセスメント加算",{"$nulls":9},"　1　なし　　　2　あり"]
[{"$nulls":4},"栄養改善加算",{"$nulls":9},"　1　なし　　　2　あり"]
[{"$nulls":4},"口腔機能向上加算",{"$nulls":9},"　1　なし　　　2　加算Ⅰ　  3　加算Ⅱ　　　　"]
[{"$nulls":4},"選択的サービス複数実施加算",{"$nulls":9},"　1　なし　　　2　あり"]
[{"$nulls":4},"事業所評価加算(申出)の有無",{"$nulls":9},"　1　なし　　　2　あり"]
[{"$nulls":4},"サービス提供体制強化加算",{"$nulls":9},"　1　なし　　　5　加算Ⅰ　　4　加算Ⅱ　　6　加算Ⅲ　　　"]
[{"$nulls":4},"生活機能向上連携加算",{"$nulls":9},"　1　なし　　　3　加算Ⅰ　　2　加算Ⅱ　　　　"]
[{"$nulls":4},"科学的介護推進体制加算",{"$nulls":9},"　1　なし　　　2　あり"]
[{"$nulls":4},"介護職員処遇改善加算",{"$nulls":9},"　1　なし　　　6　加算Ⅰ　  5　加算Ⅱ　  2　加算Ⅲ　　     　　　　　  ",{"$nulls":4},"　"]
[{"$nulls":14},"　3　加算Ⅳ 　　4　加算Ⅴ"]
[{"$nulls":4},"介護職員等特定処遇改善加算",{"$nulls":9},"　1　なし　　　2　加算Ⅰ　 3　加算Ⅱ　　　　"]