Annual Utilization Report of Home Health Agencies / Hospices
Facility Name:SILVERADO HOSPICE
OSHPD ID:406197025Report Status:Submitted
License Category:HospiceReport 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:SILVERADO HOSPICE
2.OSHPD ID Number:406197025
3.Street Address:601 S. GLENOAKS BLVD.
STE. 201
4.City:BURBANK
5.Zip:91502
6.Facility Phone No.:( 818) 848 - 4048 ext.
7.Administrator Name:Jennifer Blake
8.Administrator E-mail Address:jblake@silveradocare.com
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:Silverado Care Inc.
13.Corporate Business Address:6400 OAk Canyon #200
14.City:Irvine
15.State:CA
16.Zip:92618 - 5205
17.Person Completing Report:Angela Mouton
18.Phone No.:888-328-4558
19.Fax No.:858-565-4827
20.E-mail Address:amouton@silveradocare.com
25.Entity Type:Hospice Only
26.Entity RelationBranch
30.Submitted by:angelamouton
31.Submitted Date and Time:3/8/2018 3:38:32 PM
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:Unselected Type of Control
Medicare/Medi-Cal Certification
Line
No.		(1)
Certification
5.Unknown certification
Agency Accreditation Status
Line
No.		(1)
Accreditation Status
10.Accredited by ACHCUnknown Accreditation Status
11.Accredited by CHAPUnknown Accreditation Status
12.Accredited by JCAHOUnknown Accreditation Status
13.Accredited by otherUnknown Accreditation Status
Home Infusion Therapy / Pharmacy Only
Line
No.		(1)
15.Is your agency a licensed Pharmacy?Unspecified
16.Do you have a Registered Nurse on staff who makes home visits?Unspecified
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)No
24.Mental Health CounselingNo
25.PediatricNo
26.Psychiatric NursingNo
27.Respiratory / Pulmonary TherapyNo
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.0
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?Unspecified
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 Years00
3.21 - 30 Years00
4.31 - 40 Years00
5.41 - 50 Years00
6.51 - 60 Years00
7.61 - 70 Years00
8.71 - 80 Years00
9.81 - 90 Years00
10.91 Years and Older00
15.Total0 0
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.)0
26.Local Health Department0
27.Long Term Care Facility (SN / IC)0
28.MSSP0
29.Payer (Insurance, HMO, etc.)0
30.Physician0
31.Self0
32.Social Service Agency0
34.Other0
35.Total0
Discharges By Reasons
Line
No.		Reason for Discharge(1)
Discharges
41.Admitted to Hospital0
42.Admitted to SN / IC Facility0
43.Death0
44.Family / Friends Assumed Responsibility0
45.Lack of Funds0
46.Lack of Progress0
47.No Further Home Health Care Needed0
48.Patient Moved out of Area0
49.Patient Refused Service0
50.Physician Request0
51.Transferred to Another HHA0
52.Transferred to Home Care (Personal Care)0
53.Transferred to Hospice0
54.Transferred to Outpatient Rehabilitation0
59.Other0
60.Total0
Visits By Type Of Staff
Line
No.		Type of Staff(1)
Visits
71.Home Health Aide0
72.Nutritionist (Diet Counseling)0
73.Occupational Therapist0
74.Physical Therapist0
75.Physician0
76.Skilled Nursing0
77.Social Worker0
78.Speech Pathologist / Audiologist0
79.Spiritual and Pastoral Care0
84.Other0
85.Total0
Visits By Primary Source Of Payment
Line
No.		Source Of Payment(1)
Visits
91.Medicare0
92.Medi-Cal0
93.TRICARE (CHAMPUS)0
94.Other Third Party (Insurance, etc.)0
95.Private (Self Pay)0
96.HMO / PPO (Includes Medicare and Medi-Cal HMOs)0
97.No Reimbursement0
99.Other (Includes MSSP)0
100.Total0
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)00
2.HIV InfectionsB2000
3.Malignant Neoplasms: LungC34, C78.0, C7A.090, D02.20-D02.2200
4.Malignant Neoplasms: BreastC50, C79.2, C79.80- C79.89, D05.90-D05.9200
5.Malignant Neoplasms: IntestinesC17-C21, C26.0, C49.A3-C49.A5, C78.4, C78.5, C7A.010-C7A.02900
6.Malignant Neoplasms: All Other Sites
excluding Lung, Breast, and Intestines		C00-C96
except codes from lines 3-5		00
7.Non-Malignant Neoplasms: All SitesD10-D4900
8.Diabetes MellitusE08-E1300
9.Endocrine, Metabolic, and Nutritional Diseases; Immunity Disorders
excluding Diabetes		E00-E07, E15-E8800
10.Diseases of Blood and Blood-Forming Organs
excluding complications of care		D50-D77, D80-D8900
11.Mental, Behavioral and Neurodevelopmental DisordersF01-F9900
12.Alzheimer's DiseaseG3000
13.Diseases of Nervous System and Sense Organs
excluding complications of care		G00-G26, G31-G96, G98-H57, H60-H9400
14.Diseases of Cardiovascular SystemI10-I11, I13, I20-I5200
15.Diseases of Cerebrovascular SystemI60-I6900
16.Diseases of All Other Circulatory System
excluding complications of care		I00, I02.9, I12, I15-I16, I70-I96, I9900
17.Diseases of Respiratory System
excluding complications of care		J00-J94, J96-J9900
18.Diseases of Digestive System
excluding complications of care		K00-K90, K92-K9500
19.Diseases of Genitourinary System
excluding diseases of breast and complications of care		N00-N53, N70-N9700
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-L9900
23.Diseases of Musculoskeletal System and Connective Tissue including Pathological, Malunion and Nonunion Fractures
excluding complications of care		M00-M95, M97, M9900
24.Congenital Anomalies and Perinatal Conditions, including Birth FracturesP00-P96, Q00-Q9900
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-S99.29900
27.All other injuries
excluding fractures		S00-T34, T51-T8800
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, 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, Z7700
33.Other health services for specific procedures and aftercareZ40-Z5300
34.Visits for Evaluation and AssessmentZ00-Z1300
45.Total00
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.HIVB2000
52.Alzheimer's DiseaseG3000
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:Investor - Corporation
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.Free Standing
Location of Service Delivery
Line
No.		(1)
25.Primarily Urban
Section 6 - Hospice Services
Bereavement Services
Line
No.		Bereavement Services(1)
People Served
1.Survivors of hospice patients480
2.Survivors of persons not receiving hospice care0
Volunteer Services
Line
No.		Volunteer Services(2)
Volunteer Hours
3.Patient / Family Services1,918
4.Bereavement0
5.Administrative388
6.Medicare Reportable Hours
(sum lines 3-5)		2,306
7.Fundraising0
9.Other0
10.Total2,306
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 - RN5,089
22.Nursing - LVN4,673
23.Social Services2,047
24.Hospice Physician Services387
25.Homemaker and Home Health Aide9,920
26.Chaplain1,840
29.Other Clinical Services1,751
30.Total25,707
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 Years0000
5.21 - 30 Years1001
6.31 - 40 Years2103
7.41 - 50 Years2507
8.51 - 60 Years711018
9.61 - 70 Years2025045
10.71 - 80 Years55540109
11.81 - 90 Years911030194
12.91 + Years31880119
15.Total2092870496
Unduplicated Hospice Patients By Gender and Race
Line
No.		Race
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
21.White67990166
22.Black57012
23.Native American1001
24.Asian / Pacific Islander1315028
25.Other / Unknown1231660289
26.More than one race0000
30.Total2092870496
Unduplicated Hospice Patients By Gender And Ethnicity
Line
No.		Ethnicity
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
31.Hispanic1414028
32.Non-Hispanic861210207
33.Unknown1091520261
35.Total2092870496
Hospice Patients Discharged By Reason
Line
No.		Reason for Discharge(1)
Patients
61.Death325
62.Patient Moved Out of Area3
63.Patient Refused Service44
64.Transferred to Another Local Hospice0
65.Prognosis Extended0
66.Patient Desired Curative Treatment0
69.Other36
70.Total408
Hospice Patients Discharged By Length Of Stay
Line
No.		Length of Stay
(Days)		(1)
Patients
71.0-7 Days125
72.8-30 Days141
73.31-90 Days142
74.91-179 Days0
75.180+ Days0
85.Total408
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 Angeles36931847452
92.Ventura4573644
93.0000
94.0000
95.0000
96.0000
97.0000
98.0000
99.0000
100.Total41432583496
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-D0911580123
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-T86.390000
103.Dementia and Cerebral
Degeneration		F01-F09, F10.27, F10.97, F13.27, F13.97, F18.27, F18.97, F19.27, F19.97, G30-G32125120137
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-T86.819300030
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-T86.19130013
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-T86.497108
107.HIVB201001
108.Brain Stroke and Late EffectsA52.04, A52.05, G45, I60-I69, I97.810-I97.821263029
109.Coma, with or without Brain InjuryR40.0-R40.4, S060000
110.DiabetesE08-E130000
111.ALS*G12.210000
112.GI Disease
excluding cancer		K20-K63, K65-K68, K90-K950000
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 101-115730073
120.TOTAL390240414
*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-D0901717411418
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-T86.39033115121
3.Dementia and Cerebral DegenerationF01-F09, F10.27,
F10.97, F13.27, F13.97,
F18.27, F18.97, F19.27,
F19.97, G30-G32		01111345676
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-T86.81901135
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-T86.19011747
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-T86.4901114141
7.HIVB2000000
8.Brain Stroke and late effectsA52.04, A52.05, G45,
I60- I69, I97.810-I97.821		01122
9.Coma, with or without brain injuryR40.0-R40.4, S0601122
10.DiabetesE08-E1300000
11.ALS*G12.2100000
12.GI disease
excluding cancer		K20-K63, K65-K68, K90-K9500000
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 1-11.832893729,47014,368
20.Total8332540810,36915,780
* 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.Medicare44941,3419253541,410
2.Medi-Cal11667000667
3.Medi-Cal Managed Care11668100669
4.Managed Care000000
5.Private Insurance2398618051,009
6.Self Pay21000010
7.Charity000000
8.Veterans Administration000000
9.Other*000000
10.Total49643,67228254043,765
* 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.Home25517,4044017,444
22.Hospital00000
23.SNF10252825078
24.CLHF000000
25.RCFE / ARF / RCFCI23126,243026,243
26.ICF / MR0000
27.Prison0000
28.Homeless0000
29.Other000000
30.Total49643,67228254043,765
Section 10 - Hospice Income and Expenses Statement
Detail Of Operating Expenses
Line
No.		(1)
Total
General Service Cost Centers
30.Administrative and General$1,240,381
Inpatient Care Service
31.Inpatient - General Care$1,100
32.Inpatient - Respite Care$5,000
Program Supervision
35.Hospice Program / Team Supervision (Non-visit wages)$822,468
Visiting Services
36.Physician Services$252,756
37.Nursing Care$1,337,169
38.Rehabilitation Services (PT, OT, Speech)$1,195
39.Medical Social Services - Direct$271,427
40.Spiritual Counseling$112,125
41.Dietary Counseling$233
42.Counseling - Other$0
43.Home Health Aides and Homemakers$296,909
44.Other Visiting Services$0
Hospice Service Cost Centers
45.Drugs, Biologicals and Infusion$360,065
46.Durable Medical Equipment / Oxygen$320,405
47.Patient Transportation$17,112
48.Imaging, Lab and Diagnostics$14,254
49.Medical Supplies$144,397
50.Outpatient Services (including ER Dept.)$0
51.Radiation Therapy$0
52.Chemotherapy$0
53.Other Hospice Service Costs0
Other Hospice Costs
54.Bereavement Program Costs$1,102
55.Volunteer Program Costs$4,187
56.Fundraising$0
Other Costs
57.Other Program Costs*$1,971,799
59.Total Operating Expenses$7,174,084
* 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$8,098,800
102.Medi-Cal (Excluding SNF Room and Board)$10,316
103.Medi-Cal Managed Care (Excluding SNF Room and Board)$161,489
104.Managed Care (Non Medi-Cal)0
105.Private Insurance$253,969
106.Self-Pay$9,510
109.Other Payers0
110.Total Revenue for Hospices Four Levels of Care$8,534,084
Room & Board Revenue
1101.SNF Room & Board pass Through Receivable from Medi-Cal$481,862
1102.Medi-Cal Room & Board Contractual Payments to SNF( $408,261)
1103.Net Room & Board Revenue$73,601
1104.Total Gross Patient Revenue (Sum of Lines 110 and 1103)$8,607,685
Write-Offs and Adjustments
111.Contractual Adjustments$111,800
112.Denials / Bad Debt$94,355
113.Charity0
119.Other Write-offs and Adjustments0
120.Total Write-Offs and Adjustments (sum of lines 111 through 119)$206,155
125.Net Patient Revenue (line 1104 minus line 120)$8,401,530
Other Operating Revenue
131.Grants$0
132.Donations / Contributions$0
133.Unrelated Business Income$0
139.Other$134,331
140.Total Other Operating Revenue (sum of lines 131 through 139)$134,331
145.Total Operating Revenue (line 125 plus line 140)$8,535,861
Operating Expenses
160.Total Operating Expenses (from line 59)$7,174,084
165.Net from Operations (line 145 minus line 160)$1,361,777
170.Income Tax0
175.Net Income (line 165 minus line 170)$1,361,777
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