Annual Utilization Report of Home Health Agencies / Hospices
Facility Name:ENLOE MEDICAL CENTER HOME HEALTH AGENCY
OSHPD ID:406042325Report Status:Submitted
License Category:Home Health AgencyReport Year:2017
Table of Contents
Click on any of the links listed below to view the corresponding section.
Section 1 - General Information
Section 2 - Home Health Agency
Section 3 - Home Health Agency Patients and Visits
Section 4 - Health Care Utilization
Section 5 - Hospice Description
Section 6 - Hospice Services
Section 7 - Hospice Patient Information
Section 8 - Hospice Utilization
Section 9 - Hospice Care And Source Of Payment
Section 10 - Hospice Income and Expenses Statement
Section 11 - Hospice Inpatient Facility/Unit
General Comments
View Errors and Warnings
Section 1 - General Information
1.Facility Name:ENLOE MEDICAL CENTER HOME HEALTH AGENCY
2.OSHPD ID Number:406042325
3.Street Address:1390 E LASSEN AVE
4.City:CHICO
5.Zip:95973
6.Facility Phone No.:( 530) 332 - 6050 ext.
7.Administrator Name:Mike Wiltermood
8.Administrator E-mail Address:mike.wiltermood@enloe.org
9.Was this agency in operation at any time during the year?:Yes
10.Operation Open From:1/1/2017
11.Operation Open To:12/31/2017
12.Name of Parent Corporation:Enloe Medical Center
13.Corporate Business Address:1531 Esplanade
14.City:Chico
15.State:CA
16.Zip:95926 -
17.Person Completing Report:Matthew McLaughlin
18.Phone No.:530-332-6211
19.Fax No.:530-893-6866
20.E-mail Address:matthew.mclaughlin@enloe.org
25.Entity Type:Home Health Agency with Hospice Program
26.Entity RelationSole Facility
30.Submitted by:matthewmclaughlin
31.Submitted Date and Time:2/12/2018 10:24:20 AM
Section 2 - Home Health Agency
LICENSEE TYPE OF CONTROL
Line
No.		(1)
1.Select the one category that best describes the licensee type of control of your home health agency:Non-profit Corporation (incl. Church-related)
Medicare/Medi-Cal Certification
Line
No.		(1)
Certification
5.Medicare and Medi-Cal
Agency Accreditation Status
Line
No.		(1)
Accreditation Status
10.Accredited by ACHCNone
11.Accredited by CHAPNone
12.Accredited by JCAHODeemed Status
13.Accredited by otherNone
Home Infusion Therapy / Pharmacy Only
Line
No.		(1)
15.Is your agency a licensed Pharmacy?No
16.Do you have a Registered Nurse on staff who makes home visits?No
Note: If the facility is a licensed Pharmacy that only provides home infusion equipment, check “No” on line 40, then submit the report to OSHPD. The rest of the report is not applicable.
Special Services
Line
No.		(1)
20.AIDS ServicesNo
21.Blood TransfusionsNo
22.Enterostomal TherapyNo
23.IV Therapy (Includes Chemo and TPN)Yes
24.Mental Health CounselingNo
25.PediatricYes
26.Psychiatric NursingNo
27.Respiratory / Pulmonary TherapyYes
28.Non-hospice Palliative CareNo
29.OtherNo
Persons Receiving Services
Line
No.		(1)
30.Number of unduplicated persons seen by your agency during the reporting year.1,684
Home Health Care
Line
No.		Other Home Health Visits(1)
No. of Visits
31.Pre-Admission Screening / Evaluations0
32.Outpatient Visits0
33.Other0
34.Total0
Other Home Health Services (Home Care Service, e.g. Continous Care)
Note: Do not complete lines 50-54 if these services were provided by an organization other than your licensed agency
Line
No.		(1)
40.Did your agency perform other Home Care Services?No
41.How many total hours of other Home Care did your agency provide?0
Other Home Care Services, Staff, and Functions
Line
No.		(1)
50.Certified Nurse Assistant (CNA)No
51.Home Health AideNo
52.Homemaker ServicesNo
53.Non-intermittent Nursing (RN / LVN)No
54.OtherNo
Section 3 - Home Health Agency Patients And Visits
Patients And Visits By Age
Line
No.		Age(1)
Patients		(2)
Visits
1.0 - 10 Years00
2.11 - 20 Years725
3.21 - 30 Years18114
4.31 - 40 Years35318
5.41 - 50 Years77632
6.51 - 60 Years2141,642
7.61 - 70 Years4923,938
8.71 - 80 Years4784,225
9.81 - 90 Years3503,570
10.91 Years and Older80851
15.Total1,751 15,315
Admissions By Source Of Referral
Line
No.		Source Of Referral(1)
Admissions
21.Another Home Health Agency1
22.Clinic0
23.Family / Friend0
24.Hospice0
25.Hospital (Discharge Planner, etc.)1,607
26.Local Health Department0
27.Long Term Care Facility (SN / IC)42
28.MSSP0
29.Payer (Insurance, HMO, etc.)1
30.Physician100
31.Self0
32.Social Service Agency0
34.Other0
35.Total1,751
Discharges By Reasons
Line
No.		Reason for Discharge(1)
Discharges
41.Admitted to Hospital57
42.Admitted to SN / IC Facility0
43.Death3
44.Family / Friends Assumed Responsibility1
45.Lack of Funds0
46.Lack of Progress2
47.No Further Home Health Care Needed1,621
48.Patient Moved out of Area1
49.Patient Refused Service20
50.Physician Request0
51.Transferred to Another HHA0
52.Transferred to Home Care (Personal Care)0
53.Transferred to Hospice6
54.Transferred to Outpatient Rehabilitation0
59.Other6
60.Total1,717
Visits By Type Of Staff
Line
No.		Type of Staff(1)
Visits
71.Home Health Aide265
72.Nutritionist (Diet Counseling)0
73.Occupational Therapist1,532
74.Physical Therapist6,546
75.Physician0
76.Skilled Nursing5,900
77.Social Worker467
78.Speech Pathologist / Audiologist605
79.Spiritual and Pastoral Care0
84.Other0
85.Total15,315
Visits By Primary Source Of Payment
Line
No.		Source Of Payment(1)
Visits
91.Medicare11,571
92.Medi-Cal1,350
93.TRICARE (CHAMPUS)0
94.Other Third Party (Insurance, etc.)1,855
95.Private (Self Pay)17
96.HMO / PPO (Includes Medicare and Medi-Cal HMOs)481
97.No Reimbursement41
99.Other (Includes MSSP)0
100.Total15,315
Section 4 - Health Care Utilization
Patients And Visits By Principal Diagnosis For Which Care Was Given*
Line
No.		Principal Diagnosis
ICD-10-CM Codes
Patients
(1)		Visits
(2)
1.Infectious and Parasitic Diseases, excluding HIVA00-B99 (exclude B20)13122
2.HIV InfectionsB2000
3.Malignant Neoplasms: LungC34, C78.0, C7A.090, D02.20-D02.221299
4.Malignant Neoplasms: BreastC50, C79.2, C79.80- C79.89, D05.90-D05.92626
5.Malignant Neoplasms: IntestinesC17-C21, C26.0, C49.A3-C49.A5, C78.4, C78.5, C7A.010-C7A.029320
6.Malignant Neoplasms: All Other Sites
excluding Lung, Breast, and Intestines		C00-C96
except codes from lines 3-5		29246
7.Non-Malignant Neoplasms: All SitesD10-D49569
8.Diabetes MellitusE08-E1318183
9.Endocrine, Metabolic, and Nutritional Diseases; Immunity Disorders
excluding Diabetes		E00-E07, E15-E8815153
10.Diseases of Blood and Blood-Forming Organs
excluding complications of care		D50-D77, D80-D8916145
11.Mental, Behavioral and Neurodevelopmental DisordersF01-F99640
12.Alzheimer's DiseaseG3000
13.Diseases of Nervous System and Sense Organs
excluding complications of care		G00-G26, G31-G96, G98-H57, H60-H9461711
14.Diseases of Cardiovascular SystemI10-I11, I13, I20-I521131,066
15.Diseases of Cerebrovascular SystemI60-I6964762
16.Diseases of All Other Circulatory System
excluding complications of care		I00, I02.9, I12, I15-I16, I70-I96, I9912128
17.Diseases of Respiratory System
excluding complications of care		J00-J94, J96-J991611,492
18.Diseases of Digestive System
excluding complications of care		K00-K90, K92-K9542365
19.Diseases of Genitourinary System
excluding diseases of breast and complications of care		N00-N53, N70-N9767641
20.Diseases of Breast excluding malignant neoplasmsN60-N65

except codes from line 4		00
21.Complications of Pregnancy, Childbirth, and the PuerperiumO00-O9A00
22.Diseases of Skin and Subcutaneous Tissue
excluding complications of care		L00-L75, L80-L9919198
23.Diseases of Musculoskeletal System and Connective Tissue including Pathological, Malunion and Nonunion Fractures
excluding complications of care		M00-M95, M97, M9965602
24.Congenital Anomalies and Perinatal Conditions, including Birth FracturesP00-P96, Q00-Q9915
25.Symptoms, Signs, and Ill-Defined Conditions excluding HIV Positive TestR00-R99
except R75		60555
26.Fractures
excluding birth, pathological, malunion, and nonunion fractures		S02, S12, S22, S32, S42, S49.001-S49.199, S52, S59.001-S59.299, S62, S72, S79, S82, S89.001-S89.399, S92, S99.001-S99.29933292
27.All other injuries
excluding fractures		S00-T34, T51-T8819192
28.Poisonings and adverse effects of external causesT36-T5000
29.Complications of surgical and medical careD78, E89, G97, H59, H95, I97, J95, K91, K95, L76, M96, N98-N99, T80-T88430
30.Health services related to reproduction and developmentZ00.110-Z00.3, Z30-Z36, Z39, Z7600
31.Infants born outside hospital (infant care)Z38.1, Z38.4, Z38.700
32.Health hazards related to communicable diseases excluding HIV test resultsZ20-Z28, Z7714147
33.Other health services for specific procedures and aftercareZ40-Z538937,026
34.Visits for Evaluation and AssessmentZ00-Z1300
45.Total1,75115,315
NOTE: The list of ICD-10-CM codes excluded: V00-Y99, Z37, and Z52.
How many of the patients you reported in Section 3 "Patients and Visits by Age" Table had a principal or secondary diagnosis of HIV or Alzheimer's Disease and how many health care visits were made to them? The principal diagnosis for which an HIV or Alzheimer's patient was visited may have been a fracture, a skin infection, cancer, or any number of principal diagnoses. What we are asking relates to the number of HIV or Alzheimer's patients among your total patient load, regardless of the nature of the treatment received or the principal diagnosis of the patient.
Line
No.		ICD-10-CM Code(1)
Patients		(2)
Visits
51.HIVB20221
52.Alzheimer's DiseaseG30647
Section 5 - Hospice Description
LICENSEE TYPE OF CONTROL
Line
No.		(1)
1.Select the one category that best describes the licensee type of control of your hospice from drop down list:Non-profit Corporation (incl. Church-related)
Medicare/Medi-Cal Certification
Line
No.		(1)
Certification
5.Medicare and Medi-Cal
Hospice Accreditation Status
Line
No.		(1)
Accreditation Status
10.Accredited by ACHCNone
11.Accredited by CHAPNone
12.Accredited by JCAHOAccredited
13.Accredited by otherNone
Agency Type As Reported On Medicare Cost Report
Line
No.		(1)
20.Hospital based
Location of Service Delivery
Line
No.		(1)
25.Mixed Urban and Rural
Section 6 - Hospice Services
Bereavement Services
Line
No.		Bereavement Services(1)
People Served
1.Survivors of hospice patients0
2.Survivors of persons not receiving hospice care0
Volunteer Services
Line
No.		Volunteer Services(2)
Volunteer Hours
3.Patient / Family Services418
4.Bereavement82
5.Administrative338
6.Medicare Reportable Hours
(sum lines 3-5)		838
7.Fundraising0
9.Other180
10.Total1,018
Additional And Specialized Services
Check all services directly provided by OR contracted for by the hospice.
Line
No.		Additional and Specialized Hospice Services(1)
Services
11.Hospice Inpatient Facility / UnitNo
12.Specialized Pediatric ProgramNo
13.Bereavement services to survivors of persons not receiving hospice careNo
14.Adult Day CareNo
15.Hospice Physician Consultation VisitsNo
16.Non-hospice Palliative Care Service ProvidedNo
17.Other ServicesNo
(1) If Line 11 is checked then complete Section 11, Lines 1 through 20.
Visits By Type Of Staff
(Include After-Hours and Bereavement Visits)
Line
No.		Type of Staff(1)
Visits
21.Nursing - RN3,876
22.Nursing - LVN0
23.Social Services981
24.Hospice Physician Services34
25.Homemaker and Home Health Aide1,696
26.Chaplain0
29.Other Clinical Services536
30.Total7,123
Section 7 - Hospice Patient Information
Unduplicated Hospice Patients By Gender And Age Category
Line
No.		Age
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
1.0 - 1 Years0000
2.2 - 5 Years0000
3.6 - 10 Years0000
4.11 - 20 Years1102
5.21 - 30 Years0101
6.31 - 40 Years1001
7.41 - 50 Years3104
8.51 - 60 Years613019
9.61 - 70 Years2421045
10.71 - 80 Years4435079
11.81 - 90 Years4452096
12.91 + Years2548073
15.Total1481720320
Unduplicated Hospice Patients By Gender and Race
Line
No.		Race
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
21.White1301540284
22.Black2103
23.Native American0303
24.Asian / Pacific Islander4206
25.Other / Unknown1212024
26.More than one race0000
30.Total1481720320
Unduplicated Hospice Patients By Gender And Ethnicity
Line
No.		Ethnicity
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
31.Hispanic1112023
32.Non-Hispanic1361600296
33.Unknown1001
35.Total1481720320
Hospice Patients Discharged By Reason
Line
No.		Reason for Discharge(1)
Patients
61.Death306
62.Patient Moved Out of Area0
63.Patient Refused Service0
64.Transferred to Another Local Hospice1
65.Prognosis Extended0
66.Patient Desired Curative Treatment0
69.Other30
70.Total337
Hospice Patients Discharged By Length Of Stay
Line
No.		Length of Stay
(Days)		(1)
Patients
71.0-7 Days129
72.8-30 Days108
73.31-90 Days61
74.91-179 Days26
75.180+ Days13
85.Total337
Hospice Patient Admissions By County And Discharges By Disposition
Line
No.
(1)
County of Patients's
Residence at Time of Admission
(2)

No. of
Admissions
(3)

No. of
Deaths		(4)
No. of
Non-Death Discharges		(5)
No. of
Patients Served
91.Butte25423526250
92.Colusa1101
93.Glenn4347345
94.Sutter1101
95.Tehama2222123
96.0000
97.0000
98.0000
99.0000
100.Total32130630320
Number Of Hospice Admissions By Diagnosis
Line
No.		Diagnosis
ICD-10-CM Codes

No. of New
Admissions

(1)
Re-admissions
Previously Seen
by Another
Hospice
Program

(2)
Re-admissions
Previously Seen
by This
Hospice
Program
(3)
Total
Admissions
(1)+(2)+(3)
(4)
101.CancerC00-D0913114136
102.HeartA01.02, A18.84, A32.82, A36.81, A39.50-A39.53, A52.00, A52.03, A52.06, A54.83, B26.82, B33.20-B33.24, B37.6, B58.81, I01-I11, I13, I20-I52, I97.0-I97.191, I97.410, I97.610-I97.611, I97.710-I97.791, M05.30-M05.39, M32.11-M32.12, T82.01-T82.228, T82.510-T82.9, T86.20-T86.39370138
103.Dementia and Cerebral
Degeneration		F01-F09, F10.27, F10.97, F13.27, F13.97, F18.27, F18.97, F19.27, F19.97, G30-G32150116
104.Lung
excluding cancer		A01.03, A15, A22.1, A36.0-A36.2, A37, A42.0, A43.0, A54.5, A54.84, B00.2, B01.2, B05.2, B06.81, B08.5, B25.0, B37.1, B38.0-B38.2, B59, B77.81, J00-J99, M32.13, T81.82, T86.810-T86.819370138
105.Kidney
excluding cancer and Diabetic Kidney Disease		A02.25, A18.11, A36.84, A51.44, A54.21, I12, I15.0-I15.1, M32.14-M32.15, N00-N29, T82.4, T86.10-T86.190000
106.Liver
excluding cancer		A06.4, A51.45, A52.74, B00.81, B15-B19, B25.1, B26.81, B58.1, B67.0, B67.5, B67.8, K70-K77, K91.82, T86.40-T86.498008
107.HIVB200000
108.Brain Stroke and Late EffectsA52.04, A52.05, G45, I60-I69, I97.810-I97.8213003
109.Coma, with or without Brain InjuryR40.0-R40.4, S060000
110.DiabetesE08-E137007
111.ALS*G12.211001
112.GI Disease
excluding cancer		K20-K63, K65-K68, K90-K952002
113.Multiple SclerosisG350000
114.Congenital DefectsQ00-Q990000
115.General Debility and Failure to ThriveG93.3, R41.81, R53.8, R54, R62.51, R62.70000
119.OtherAll other codes that are not in lines 101-115870188
120.TOTAL32818337
*Amytrophic lateral sclerosis (ALS), also called Lou Gehrig's Disease
Section 8 - Hospice Utilization
Please provide the number of patients discharged during calendar year reported regardless of payment source. Count the patient only under the principal diagnosis for which the patient was admitted for hospice care. Report each patient only once. The ICD-10-CM codes are provided only as a guide to you. You may use definitions for diagnosis groups or the Local Medical Review Policy (LMRP) diagnosis codes from your fiscal intermediary, provided they match in a general way with the ICD-10-CM codes.
Discharged Hospice Patients, Visits And Patient Days By Diagnosis
Line
No.		Diagnosis
ICD-10-CM Codes
Number of Live Discharges

(1)
No. of Discharges due to Death

(2)
Total Number of Discharges

(3)
Visits for Discharged Patients

(4)
Discharged Patients Total Days of Care

(5)
1.CancerC00-D09131681813,6146,620
2.HeartA01.02, A18.84, A32.82, A36.81, A39.50-A39.53, A52.00, A52.03, A52.06, A54.83, B26.82, B33.20-B33.24, B37.6, B58.81, I01- I11, I13, I20-I52, I97.0-I97.191, I97.410, I97.610-I97.611, I97.710-I97.791, M05.30-M05.39, M32.11-M32.12, T82.01-T82.228, T82.510-T82.9, T86.20-T86.3941923619850
3.Dementia and Cerebral DegenerationF01-F09, F10.27,
F10.97, F13.27, F13.97,
F18.27, F18.97, F19.27,
F19.97, G30-G32		01010339456
4.Lung
excluding cancer		A01.03, A15, A22.1, A36.0-A36.2, A37, A42.0, A43.0, A54.5, A54.84, B00.2, B01.2 B05.2, B06.81, B08.5, B25.0, B37.1, B38.0-B38.2 B59, B77.81, J00-J99, M32.13, T81.82, T86.810-T86.819430341,0781,730
5.Kidney
excluding cancer and Diabetic Kidney Disease		A02.25, A18.11, A36.84, A51.44, A54.21, I12, I15.0- I15.1, M32.14-M32.15, N00- N29, T82.4, T86.10-T86.1900000
6.Liver
excluding cancer		A06.4, A51.45, A52.74, B00.81, B15-B19, B25.1, B26.81, B58.1, B67.0, B67.5, B67.8, K70-K77, K91.82, T86.40-T86.490553731
7.HIVB2000000
8.Brain Stroke and late effectsA52.04, A52.05, G45,
I60- I69, I97.810-I97.821		0111010
9.Coma, with or without brain injuryR40.0-R40.4, S0600000
10.DiabetesE08-E1300000
11.ALS*G12.210112735
12.GI disease
excluding cancer		K20-K63, K65-K68, K90-K950111111
13.Multiple SclerosisG3500000
14.Congenital DefectsQ00-Q9900000
15.General Debility and Failure to ThriveG93.3, R41.81, R53.8, R54, R62.51, R62.700000
19.OtherAll other codes that are not in lines 1-11.972812,2473,821
20.Total303073377,98213,564
* Amyotrophic lateral sclerosis (ALS), also called Lou Gehrig's Disease
Section 9 - Hospice Care and Source of Payment
Please provide patient days for all patients served, including those in nursing facilities during the calendar year reported. Patients who change primary pay source during the calendar year reported should be reported for each pay source with the number of days of care recorded for each source (count each day only once even if there is more than one pay source on any one day).
Level of Care and Source of Payment
Line
No.		Source of Payment(1)
No. of Patients Served		(2)
Days of Routine Home Care		(3)
Days of Inpatient Care		(4)
Days of Inpatient Respite Care		(5)
Days of Continuous Care		(6)
Total Patient Care Days
1.Medicare26710,97600010,976
2.Medi-Cal14838000838
3.Medi-Cal Managed Care19792000792
4.Managed Care000000
5.Private Insurance18917000917
6.Self Pay11000010
7.Charity000000
8.Veterans Administration13100031
9.Other*000000
10.Total32013,56400013,564
* Other payment sources may include but not limited to Workers Comp., Home Health benefit, etc.
Location of Care Provided
Line
No.		Location of Care(1)
No. of Patients Served		(2)
Days of Routine Home Care		(3)
Days of Inpatient Care		(4)
Days of Inpatient Respite Care		(5)
Days of Continuous Care
(6)

Total Patient Care Days
21.Home2419,11409,114
22.Hospital00000
23.SNF301,8370001,837
24.CLHF000000
25.RCFE / ARF / RCFCI482,51902,519
26.ICF / MR0000
27.Prison0000
28.Homeless0000
29.Other19400094
30.Total32013,56400013,564
Section 10 - Hospice Income and Expenses Statement
Detail Of Operating Expenses
Line
No.		(1)
Total
General Service Cost Centers
30.Administrative and General$0
Inpatient Care Service
31.Inpatient - General Care$0
32.Inpatient - Respite Care$0
Program Supervision
35.Hospice Program / Team Supervision (Non-visit wages)$0
Visiting Services
36.Physician Services$42,250
37.Nursing Care$1,116,392
38.Rehabilitation Services (PT, OT, Speech)$117,666
39.Medical Social Services - Direct$154,835
40.Spiritual Counseling$0
41.Dietary Counseling$0
42.Counseling - Other$0
43.Home Health Aides and Homemakers$149,904
44.Other Visiting Services$0
Hospice Service Cost Centers
45.Drugs, Biologicals and Infusion$0
46.Durable Medical Equipment / Oxygen$0
47.Patient Transportation$0
48.Imaging, Lab and Diagnostics$0
49.Medical Supplies$92,700
50.Outpatient Services (including ER Dept.)$0
51.Radiation Therapy$0
52.Chemotherapy$0
53.Other Hospice Service Costs$143,191
Other Hospice Costs
54.Bereavement Program Costs$0
55.Volunteer Program Costs$0
56.Fundraising$0
Other Costs
57.Other Program Costs*$48,630
59.Total Operating Expenses$1,865,568
* Program costs including community education and outreach program costs.
Hospice Income Statement
Line
No.		(1)
Total
Gross Patient Revenue
Gross Patient Revenue for Hospice Four Levels of Care
101.Medicare$2,137,681
102.Medi-Cal (Excluding SNF Room and Board)$142,484
103.Medi-Cal Managed Care (Excluding SNF Room and Board)$123,388
104.Managed Care (Non Medi-Cal)$0
105.Private Insurance$167,330
106.Self-Pay$2,894
109.Other Payers$0
110.Total Revenue for Hospices Four Levels of Care$2,573,777
Room & Board Revenue
1101.SNF Room & Board pass Through Receivable from Medi-Cal$0
1102.Medi-Cal Room & Board Contractual Payments to SNF( $0)
1103.Net Room & Board Revenue$0
1104.Total Gross Patient Revenue (Sum of Lines 110 and 1103)$2,573,777
Write-Offs and Adjustments
111.Contractual Adjustments$49,780
112.Denials / Bad Debt$0
113.Charity$0
119.Other Write-offs and Adjustments$0
120.Total Write-Offs and Adjustments (sum of lines 111 through 119)$49,780
125.Net Patient Revenue (line 1104 minus line 120)$2,523,997
Other Operating Revenue
131.Grants$0
132.Donations / Contributions$0
133.Unrelated Business Income$0
139.Other$52,147
140.Total Other Operating Revenue (sum of lines 131 through 139)$52,147
145.Total Operating Revenue (line 125 plus line 140)$2,576,144
Operating Expenses
160.Total Operating Expenses (from line 59)$1,865,568
165.Net from Operations (line 145 minus line 160)$710,576
170.Income Tax0
175.Net Income (line 165 minus line 170)$710,576
Section 11 - Hospice Inpatient Facility/Unit
HOSPICE OPERATED SITES AND NUMBER OF BEDS
Line
No.		(1)
Name		(2)
Address		(3)
City		(4)
State		(5)
Zip		(6)
Type of Licensed Beds		(7)
No. of Beds
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.Total0
LEVELS OF CARE HOSPICE SITES PROVIDE
Line
No.		Type of Care(1)
No. of Patient days
11.General Inpatient Care0
12.Inpatient Respite care0
13.Continuous Care0
14.Routine Care0
20TOTAL0
General Comments:
Errors and Warnings