Annual Utilization Report of Home Health Agencies / Hospices
Facility Name:HOSPICE OF PETALUMA - PARENT
OSHPD ID:406494059Report Status:Submitted
License Category:HospiceReport Year:2005
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
General Comments
View Errors and Warnings
Section 1 - General Information
1.Facility Name:HOSPICE OF PETALUMA - PARENT
2.OSHPD ID Number:406494059
3.Street Address:416 PAYRAN STREET
4.City:PETALUMA
5.Zip:94952
6.Facility Phone No.:( 707) 778 - 6242 ext.
7.Administrator Name:Judy Ryder
8.Administrator E-mail Address:Judy.Ryder@stjoe.org
9.Was this agency in operation at any time during the year?:Yes
10.Operation Open From:1/1/2005
11.Operation Open To:12/31/2005
12.Name of Parent Corporation:SRM Alliance Hospital Service
13.Corporate Business Address:c/o Petaluma Valley Hospital
400 N. McDowell Blvd.
14.City:Petaluma
15.State:CA
16.Zip:94954 -
17.Person Completing Report:Debra Terra
18.Phone No.:707-778-6242
19.Fax No.:707-778-0144
20.E-mail Address:DTERRA@PVH.STJOE.ORG
25.Entity Type:Hospice Only
26.Entity RelationParent
30.Submitted by:406494059
31.Submitted Date and Time:4/13/2006 7:51:21 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: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.OtherNo
Patient Information
Line
No.		(1)
30.Number of unduplicated patients 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 DiagnosisICD-9-CM Code(1)
Patients		(2)
Visits
1.Infectious and Parasitic diseases (exclude HIV)001.0 - 041.9
045.00 - 139.8		00
2.HIV infections04200
3.Malignant neoplasms: Lung162.0 - 162.9
197.0, 231.2		00
4.Malignant neoplasms: Breast174.0 - 174.9
175.0 - 175.9
198.2, 198.81, 233.0		00
5.Malignant neoplasms: Intestines152.0 - 154.8
159.0,  197.4,  197.5,  197.8
198.89, 230.3, 230.4, 230.7		00
6.Malignant neoplasms: All other sites, excluding those in #3, 4, 5140.0 - 208.91
230.0 - 234.9		00
7.Non-malignant neoplasms: All sites210.0 - 229.9
235.0 - 238.9
239.0 - 239.9		00
8.Diabetes mellitus250.00 - 250.9300
9.Endocrine, metabolic, and nutritional diseases; Immunity disorders240.0 - 246.9
251.0 - 279.9		00
10.Diseases of blood and blood forming organs280.0 - 289.900
11.Mental disorder290.0 - 31900
12.Alzheimer's disease331.000
13.Disease of nervous system and sense organs320.0 - 330.9
331.11 - 389.9		00
14.Diseases of cardiovascular system391.0 - 392.0
393 - 402.91
404.00 - 429.9		00
15.Diseases of cerebrovascular system430 - 438.900
16.Diseases of all other circulatory system390,  392.9
403.00 - 403.91
440.0 - 459.9		00
17.Diseases of respiratory system460 - 519.900
18.Diseases of digestive system520.0 - 579.900
19.Diseases of genitourinary system580.0 - 608.9
614.0 - 629.9		00
20.Diseases of breast610.0 - 611.900
21.Complications of pregnancy, childbirth, and the puerperium630 - 67700
22.Diseases of skin and subcutaneous tissue680.0 - 709.900
23.Diseases of musculosketal system and connective tissue (include pathological fx, malunion fx, and nonunion fx)710.00 - 739.900
24.Congenital anormalies and perinatal conditions (include birth fractures)740.0 - 779.900
25.Symptoms, signs, and ill-defined conditions (exclude HIV positive test)780.01 - 795.6
795.79
796.0 - 799.9		00
26.Fractures (exclude birth fx, pathological fx, malunion fx, nonunion fx)800.00 - 829.100
27.All other injuries830.0 - 959.900
28.Poisonings and adverse effects of external causes960.0 - 995.9400
29.Complications of surgical and medical care996.00 - 999.900
30.Health services related to reproduction and developmentV20.0 - V26.9
V28.0 - V29.9		00
31.Infants born outside hospital (infant care)V30.1,  V30.2,  V31.1,  V31.2,  V32.1
V32.2,  V33.1,  V33.2,  V34.1,  V34.2
V35.1,  V35.2,  V36.1,  V36.2,  V37.1
V37.2, V39.1, V39.2		00
32.Health hazards related to communicable diseasesV01.0 - V07.9
V09.0 - V19.8
V40.0 - V49.9		00
33.Other health services for specific procedures and aftercareV50.0 - V58.900
34.Visits for Evaluation and AssessmentV60.0 - V84.800
45.Total00
* The list of ICD-9-CM codes excluded: 795.71, V08, V27.0-V27.9, V59.01-V59.9
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-9-CM Code(1)
Patients		(2)
Visits
51.HIV04200
52.Alzheimer's Disease331.000
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
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 patients63
2.Survivors of persons not receiving hospice care151
Volunteer Services
Line
No.		Volunteer Services(1)
No. of Volunteers		(2)
Volunteer Hours
3.Patient / Family Services1031,093
4.Bereavement114546
5.Administrative261,424
6.Medicare Reportable Hours
(sum lines 3-5)		3,063
7.Fundraising80891
9.Other13718,247
10.Total46022,201
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 Designated Inpatient Facility / UnitNo
12.Specialized Pediatric ProgramNo
13.Bereavement services to survivors of persons not receiving hospice careYes
14.Adult Day CareNo
15.Specialized Palliative Care ProgramNo
16.OtherNo
Visits By Type Of Staff
(Include After-Hours and Bereavement Visits)
Line
No.		Type of Staff(1)
Visits
21.Nursing - RN6,809
22.Nursing - LVN345
23.Social Services1,363
24.Hospice Physician Services0
25.Homemaker and Home Health Aide3,289
26.Chaplain437
29.Other Clinical Services0
30.Total12,243
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 Years2002
6.31 - 40 Years1001
7.41 - 50 Years5308
8.51 - 60 Years816024
9.61 - 70 Years3025055
10.71 - 80 Years4751098
11.81 - 90 Years60970157
12.91 + Years1842060
15.Total1712340405
Unduplicated Hospice Patients By Gender and Race
Line
No.		Race(1)
Male		(2)
Female		(3)
Other / Unknown		(4)
Total
21.White1582220380
22.Black2204
23.Native American2103
24.Asian / Pacific Islander1304
25.Other / Unknown86014
30.Total1712340405
Unduplicated Hospice Patients By Gender And Ethnicity
Line
No.		Ethnicity(1)
Male		(2)
Female		(3)
Other / Unknown		(4)
Total
31.Hispanic86014
32.Non-Hispanic1632280391
33.Unknown0000
35.Total1712340405
Hospice Patient Admissions By Source Of Referral
Line
No.		Source of Referral(1)
Patients
41.Home Health Agency3
42.Hospital (Discharge Planner, etc.)25
43.Long-Term Care Facility24
44.Other Hospice0
45.Payer (Insure, HMO,etc.)0
46.Physician231
47.RCFE / ARFCLHF1
48.Self / Family / Friend76
49.Social Service Agency0
54.Other7
55.Total367
Hospice Patient Discharges By Reason
Line
No.		Reason for Discharge(1)
Patients
61.Death338
62.Patient Moved Out of Area2
63.Patient Refused Service5
64.Transferred to Another Local Hospice0
65.Prognosis Extended19
66.Patient Desired Curative Treatment3
69.Other5
70.Total372
Hospice Patients Discharged By Length Of Stay
Line
No.		Length of Stay
(Days)		(1)
Patients
71.0-5 Days81
72.6-10 Days56
73.11-15 Days30
74.16-20 Days22
75.21-30 Days32
76.31-60 Days58
77.61-90 Days32
78.91-120 Days17
79.121-150 Days11
80.151-180 Days11
84.181 + Days22
85.Total372
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.Marin8809
92.Sonoma35933034396
93.00000
94.00000
95.00000
96.00000
97.00000
98.00000
99.00000
100.Total36733834405
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-9-CM codes are provided only as a guide for you. You may use your hospice's existing definitions for diagnosis groups or the LMRP diagnosis codes from your fiscal intermediary, provided they match in a general way with the ICD-9-CM codes suggested.
Discharged Hospice Patient's Visits And Patient Days By Diagnosis
Line
No.		DiagnosisICD-9-CM Code(1)
No. of Patient Discharges		(2)
Visits for Discharged Patients		(3)
Discharged Patients Total Days of Care
1.Cancer140.0 - 208.91
230.0 - 234.9		1765,1647,599
2.Heart391.0 - 392.0
393 - 402.91
404.0 - 404.9 with fifth digit 1 or 3
410.00 - 429.9		351,0061,281
3.Dementia and Cerebral Degeneration290.0 - 294.9
331.0-331.9		16550762
4.Lung, excluding cancer460 - 519.913530713
5.Kidney, excluding cancer403.00 - 403.91
404.0 - 404.9 with fifth digit 2 or 3
405.0 - 405.9 with fifth digit 1
580.0 - 589.9		13214211
6.Liver, excluding cancer570 - 573.99151191
7.HIV042000
8.Brain Stroke and late effects430 - 436
438.0 - 438.9
997.02		64252
9.Coma, with or without brain injury780.01 - 780.09
850.4
851.0 - 854.1 with fifth digit 5		000
10.Diabetes250.00 - 250.93144
11.ALS*335.20000
19.OtherAll other codes that are not in lines 1-11.1032,9873,661
20.Total37210,64814,474
* 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 Respite Care		(5)
Days of Continuous Care		(6)
Total Patient Care Days
1.Medicare34616,7062623016,755
2.Medi-Cal17639800647
3.Medi-Cal Managed Care000000
4.Managed Care19618000618
5.Private Insurance19668200670
6.Self Pay000000
7.Charity4130000130
9.Other*000000
10.Total40518,7613623018,820
* 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)
Days of Routine Home Care		(2)
Days of Inpatient Care		(3)
Days of Respite Care		(4)
Days of Continuous Care		(5)
Total Patient Care Days
21.Home13,25723013,280
22.Hospital730037
23.SNF4,1326004,138
24.CLHF00000
25.RCFE / ARF1,365001,365
29.Other00000
30.Total18,7613623018,820
Section 10 - Hospice Income and Expenses Statement
Detail Of Operating Expenses
Line
No.		(1)
Total
General Service Cost Centers
30.Administrative and General$561,263
Inpatient Care Service
31.Inpatient - General Care$0
32.Inpatient - Respite Care$0
Nursing Home
33.Room and Board SNFMedi-Cal Pass through Payments( $0 )
34.Medi-Cal Room and Board Contractual Payments$0
Program Supervision
35.Hospice Program / Team Supervision (Non-visit wages)$0
Visiting Services
36.Physician Services$0
37.Nursing Care$617,974
38.Rehabilitation Services (PT, OT, Speech)$788
39.Medical Social Services - Direct$1,025,998
40.Spiritual Counseling$0
41.Dietary Counseling$0
42.Counseling - Other$0
43.Home Health Aides and Homemakers$151,579
44.Other Visiting Services$0
Hospice Service Cost Centers
45.Drugs, Biologicals and Infusion$230,639
46.Durable Medical Equipment / Oxygen$209,074
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 Costs$4,032
56.Fundraising$0
Other Costs
57.Other Program Costs*$0
59.Total Operating Expenses$2,801,347
* Program costs including community education and outreach program costs.
Hospice Income Statement
Line
No.		(1)
Total
Gross Patient Revenue
101.Medicare$3,102,832
102.Medi-Cal (Excluding Room and Board)$71,413
103.Medi-Cal Managed Care (Excluding Room and Board)$0
104.Managed Care (Non Medi-Cal)$79,848
105.Private Insurance$79,848
106.Self-Pay$0
109.Other Payers$0
110.Total Gross Patient Revenue (sum of lines 101 through 109)$3,333,941
Write-Offs and Adjustments
111.Contractual Adjustments$902,354
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)$902,354
125.Net Patient Revenue (line 110 minus line 120)$2,431,587
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)$2,431,587
Operating Expenses
151.General Service Cost Centers$561,263
152.Inpatient Care Service$0
153.Nursing Home$0
154.Program Supervision$0
155.Visiting Services$1,796,339
156.Hospice Service Cost Centers$439,713
157.Other Hospice Costs$4,032
159.Other Costs$0
160.Total Operating Expenses (sum of lines 151 through 159)$2,801,347
165.Net from Operations (line 145 minus line 160)-$369,760
170.Income Tax$0
175.Net Income (line 165 minus line 170)-$369,760
General Comments:
Errors and Warnings