Annual Utilization Report of Home Health Agencies / Hospices
Facility Name:KAISER FOUNDATION HOSPITAL HHA
OSHPD ID:406361335Report 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:KAISER FOUNDATION HOSPITAL HHA
2.OSHPD ID Number:406361335
3.Street Address:17284 SLOVER AVE
4.City:FONTANA
5.Zip:92337
6.Facility Phone No.:( 909) 609 - 3800 ext.
7.Administrator Name:Catherine Bocanegra
8.Administrator E-mail Address:Catherine.L.Bocanegra@kp.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:
13.Corporate Business Address:
14.City:
15.State:
16.Zip:-
17.Person Completing Report:Isabella Barrans
18.Phone No.:909-609-3844
19.Fax No.:909-609-3802
20.E-mail Address:Isabella.j.barrans@kp.org
25.Entity Type:Home Health Agency with Hospice Program
26.Entity RelationSole Facility
30.Submitted by:isabellabarrans
31.Submitted Date and Time:3/12/2018 11:16:19 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 otherDeemed Status
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?Yes
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 TherapyNo
28.Non-hospice Palliative CareYes
29.OtherNo
Persons Receiving Services
Line
No.		(1)
30.Number of unduplicated persons seen by your agency during the reporting year.4,471
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 Years107309
2.11 - 20 Years72410
3.21 - 30 Years95808
4.31 - 40 Years1281,091
5.41 - 50 Years2772,397
6.51 - 60 Years7445,685
7.61 - 70 Years1,30910,048
8.71 - 80 Years1,2119,710
9.81 - 90 Years8718,123
10.91 Years and Older2432,632
15.Total5,057 41,213
Admissions By Source Of Referral
Line
No.		Source Of Referral(1)
Admissions
21.Another Home Health Agency0
22.Clinic0
23.Family / Friend0
24.Hospice0
25.Hospital (Discharge Planner, etc.)3,204
26.Local Health Department3
27.Long Term Care Facility (SN / IC)446
28.MSSP0
29.Payer (Insurance, HMO, etc.)0
30.Physician885
31.Self0
32.Social Service Agency0
34.Other1
35.Total4,539
Discharges By Reasons
Line
No.		Reason for Discharge(1)
Discharges
41.Admitted to Hospital193
42.Admitted to SN / IC Facility73
43.Death95
44.Family / Friends Assumed Responsibility318
45.Lack of Funds0
46.Lack of Progress2
47.No Further Home Health Care Needed2,335
48.Patient Moved out of Area28
49.Patient Refused Service174
50.Physician Request11
51.Transferred to Another HHA50
52.Transferred to Home Care (Personal Care)0
53.Transferred to Hospice222
54.Transferred to Outpatient Rehabilitation1,034
59.Other29
60.Total4,564
Visits By Type Of Staff
Line
No.		Type of Staff(1)
Visits
71.Home Health Aide3,285
72.Nutritionist (Diet Counseling)0
73.Occupational Therapist1,513
74.Physical Therapist11,884
75.Physician0
76.Skilled Nursing22,720
77.Social Worker1,799
78.Speech Pathologist / Audiologist0
79.Spiritual and Pastoral Care12
84.Other0
85.Total41,213
Visits By Primary Source Of Payment
Line
No.		Source Of Payment(1)
Visits
91.Medicare70
92.Medi-Cal93
93.TRICARE (CHAMPUS)0
94.Other Third Party (Insurance, etc.)5
95.Private (Self Pay)35
96.HMO / PPO (Includes Medicare and Medi-Cal HMOs)40,929
97.No Reimbursement66
99.Other (Includes MSSP)15
100.Total41,213
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)19166
2.HIV InfectionsB2000
3.Malignant Neoplasms: LungC34, C78.0, C7A.090, D02.20-D02.22313
4.Malignant Neoplasms: BreastC50, C79.2, C79.80- C79.89, D05.90-D05.925126
5.Malignant Neoplasms: IntestinesC17-C21, C26.0, C49.A3-C49.A5, C78.4, C78.5, C7A.010-C7A.02912
6.Malignant Neoplasms: All Other Sites
excluding Lung, Breast, and Intestines		C00-C96
except codes from lines 3-5		90944
7.Non-Malignant Neoplasms: All SitesD10-D4911
8.Diabetes MellitusE08-E1333478
9.Endocrine, Metabolic, and Nutritional Diseases; Immunity Disorders
excluding Diabetes		E00-E07, E15-E888106
10.Diseases of Blood and Blood-Forming Organs
excluding complications of care		D50-D77, D80-D8979731
11.Mental, Behavioral and Neurodevelopmental DisordersF01-F9900
12.Alzheimer's DiseaseG3065799
13.Diseases of Nervous System and Sense Organs
excluding complications of care		G00-G26, G31-G96, G98-H57, H60-H942086
14.Diseases of Cardiovascular SystemI10-I11, I13, I20-I523913,086
15.Diseases of Cerebrovascular SystemI60-I6974545
16.Diseases of All Other Circulatory System
excluding complications of care		I00, I02.9, I12, I15-I16, I70-I96, I995114
17.Diseases of Respiratory System
excluding complications of care		J00-J94, J96-J99100948
18.Diseases of Digestive System
excluding complications of care		K00-K90, K92-K9547415
19.Diseases of Genitourinary System
excluding diseases of breast and complications of care		N00-N53, N70-N9749383
20.Diseases of Breast excluding malignant neoplasmsN60-N65

except codes from line 4		222
21.Complications of Pregnancy, Childbirth, and the PuerperiumO00-O9A3072
22.Diseases of Skin and Subcutaneous Tissue
excluding complications of care		L00-L75, L80-L996219,870
23.Diseases of Musculoskeletal System and Connective Tissue including Pathological, Malunion and Nonunion Fractures
excluding complications of care		M00-M95, M97, M991,6507,949
24.Congenital Anomalies and Perinatal Conditions, including Birth FracturesP00-P96, Q00-Q991029
25.Symptoms, Signs, and Ill-Defined Conditions excluding HIV Positive TestR00-R99
except R75		00
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-S99.2993171,921
27.All other injuries
excluding fractures		S00-T34, T51-T8821232
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-T8800
30.Health services related to reproduction and developmentZ00.110-Z00.3, Z30-Z36, Z39, Z76418
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, Z7700
33.Other health services for specific procedures and aftercareZ40-Z5348
34.Visits for Evaluation and AssessmentZ00-Z131,40812,149
45.Total5,05741,213
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.HIVB2026
52.Alzheimer's DiseaseG30136898
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 JCAHODeemed Status
13.Accredited by otherNone
Agency Type As Reported On Medicare Cost Report
Line
No.		(1)
20.Home Health 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 patients617
2.Survivors of persons not receiving hospice care0
Volunteer Services
Line
No.		Volunteer Services(2)
Volunteer Hours
3.Patient / Family Services231
4.Bereavement0
5.Administrative993
6.Medicare Reportable Hours
(sum lines 3-5)		1,224
7.Fundraising0
9.Other0
10.Total1,224
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 careYes
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 - RN4,326
22.Nursing - LVN1,463
23.Social Services1,316
24.Hospice Physician Services110
25.Homemaker and Home Health Aide3,089
26.Chaplain636
29.Other Clinical Services23
30.Total10,963
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 Years2002
5.21 - 30 Years3104
6.31 - 40 Years0101
7.41 - 50 Years1012022
8.51 - 60 Years2628054
9.61 - 70 Years75770152
10.71 - 80 Years99760175
11.81 - 90 Years1071370244
12.91 + Years32920124
15.Total3544240778
Unduplicated Hospice Patients By Gender and Race
Line
No.		Race
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
21.White2633160579
22.Black2241063
23.Native American2204
24.Asian / Pacific Islander813021
25.Other / Unknown59520111
26.More than one race0000
30.Total3544240778
Unduplicated Hospice Patients By Gender And Ethnicity
Line
No.		Ethnicity
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
31.Hispanic3527062
32.Non-Hispanic3183940712
33.Unknown1304
35.Total3544240778
Hospice Patients Discharged By Reason
Line
No.		Reason for Discharge(1)
Patients
61.Death583
62.Patient Moved Out of Area25
63.Patient Refused Service106
64.Transferred to Another Local Hospice77
65.Prognosis Extended35
66.Patient Desired Curative Treatment17
69.Other0
70.Total843
Hospice Patients Discharged By Length Of Stay
Line
No.		Length of Stay
(Days)		(1)
Patients
71.0-7 Days198
72.8-30 Days344
73.31-90 Days192
74.91-179 Days72
75.180+ Days37
85.Total843
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.Los Angeles847916100
92.Riverside1311113
93.San Bernardino591493134668
94.San Diego1011
95.0000
96.0000
97.0000
98.0000
99.0000
100.Total689583152782
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-D0934254156552
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-T86.391081647171
103.Dementia and Cerebral
Degeneration		F01-F09, F10.27, F10.97, F13.27, F13.97, F18.27, F18.97, F19.27, F19.97, G30-G3219234284
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-T86.81930153580
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-T86.192431037
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-T86.49122418
107.HIVB203025
108.Brain Stroke and Late EffectsA52.04, A52.05, G45, I60-I69, I97.810-I97.8212571547
109.Coma, with or without Brain InjuryR40.0-R40.4, S064004
110.DiabetesE08-E130000
111.ALS*G12.216017
112.GI Disease
excluding cancer		K20-K63, K65-K68, K90-K950000
113.Multiple SclerosisG353025
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 101-115912598
120.TOTAL6671223191,108
*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-D09273954223,8457,199
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-T86.39111571681,4222,419
3.Dementia and Cerebral DegenerationF01-F09, F10.27,
F10.97, F13.27, F13.97,
F18.27, F18.97, F19.27,
F19.97, G30-G32		00000
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-T86.819279223430
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-T86.1921416323528
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-T86.4936913224
7.HIVB201013171
8.Brain Stroke and late effectsA52.04, A52.05, G45,
I60- I69, I97.810-I97.821		21315287790
9.Coma, with or without brain injuryR40.0-R40.4, S0603385109
10.DiabetesE08-E1300000
11.ALS*G12.21044186259
12.GI disease
excluding cancer		K20-K63, K65-K68, K90-K9500000
13.Multiple SclerosisG351017176
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 1-11.181771951,8063,907
20.Total677768438,22816,112
* 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.Medicare1,07715,81919858,42474,270
2.Medi-Cal000000
3.Medi-Cal Managed Care7462000462
4.Managed Care45418,949100619,009
5.Private Insurance000000
6.Self Pay150005
7.Charity000000
8.Veterans Administration000000
9.Other*4394,542103816,93021,520
10.Total1,97839,777399075,360115,266
* 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.Home1,51934,47958,43092,909
22.Hospital00000
23.SNF315329520234
24.CLHF000000
25.RCFE / ARF / RCFCI176030603
26.ICF / MR0000
27.Prison0000
28.Homeless0000
29.Other4394,542103816,93021,520
30.Total1,97839,777399075,360115,266
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$0
37.Nursing Care$0
38.Rehabilitation Services (PT, OT, Speech)$0
39.Medical Social Services - Direct$0
40.Spiritual Counseling$0
41.Dietary Counseling$0
42.Counseling - Other$0
43.Home Health Aides and Homemakers$0
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$0
50.Outpatient Services (including ER Dept.)$0
51.Radiation Therapy$0
52.Chemotherapy$0
53.Other Hospice Service Costs$0
Other Hospice Costs
54.Bereavement Program Costs$0
55.Volunteer Program Costs0
56.Fundraising0
Other Costs
57.Other Program Costs*0
59.Total Operating Expenses$0
* 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$0
102.Medi-Cal (Excluding SNF Room and Board)$0
103.Medi-Cal Managed Care (Excluding SNF Room and Board)$0
104.Managed Care (Non Medi-Cal)$0
105.Private Insurance$0
106.Self-Pay$0
109.Other Payers$0
110.Total Revenue for Hospices Four Levels of Care$0
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)$0
Write-Offs and Adjustments
111.Contractual Adjustments$0
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)$0
125.Net Patient Revenue (line 1104 minus line 120)$0
Other Operating Revenue
131.Grants$0
132.Donations / Contributions$0
133.Unrelated Business Income$0
139.Other$0
140.Total Other Operating Revenue (sum of lines 131 through 139)$0
145.Total Operating Revenue (line 125 plus line 140)$0
Operating Expenses
160.Total Operating Expenses (from line 59)$0
165.Net from Operations (line 145 minus line 160)$0
170.Income Tax$0
175.Net Income (line 165 minus line 170)$0
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 Care15
12.Inpatient Respite care52
13.Continuous Care6
14.Routine Care20,059
20TOTAL20,132
General Comments:
Errors and Warnings