Annual Utilization Report of Home Health Agencies / Hospices
Facility Name:KAISER FOUNDATION HOSPITAL HHA - FONTANA
OSHPD ID:406361335Report Status:Revised
License Category:Home Health AgencyReport 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:KAISER FOUNDATION HOSPITAL HHA - FONTANA
2.OSHPD ID Number:406361335
3.Street Address:9961 SIERRA AVENUE BLDG 3-A
4.City:FONTANA
5.Zip:92335
6.Facility Phone No.:( 909) 427 - 7727 ext.
7.Administrator Name:Nanette Antonio
8.Administrator E-mail Address:Nanette.V.Antonio@kp.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:Kaiser Permanente
13.Corporate Business Address:Kaiser Foundation Hospital
9985 Sierra Ave Bld 3A
14.City:Fontana
15.State:CA
16.Zip:92335 -
17.Person Completing Report:Adele Helton
18.Phone No.:909-427-5875
19.Fax No.:909-427-5723
20.E-mail Address:adele.x.helton@kp.org
25.Entity Type:Home Health Agency with Hospice Program
26.Entity RelationParent
30.Submitted by:ahelton
31.Submitted Date and Time:4/19/2006 5:31:09 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:Non-profit Corporation
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 JCAHOAccredited
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?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)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.3,835
Home Health Care
Line
No.		Other Home Health Visits(1)
No. of Visits
31.Pre-Admission Screening / Evaluations235
32.Outpatient Visits0
33.Other30
34.Total265
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 Years95158
2.11 - 20 Years52304
3.21 - 30 Years67423
4.31 - 40 Years113756
5.41 - 50 Years2352,174
6.51 - 60 Years4874,015
7.61 - 70 Years8487,221
8.71 - 80 Years1,0689,260
9.81 - 90 Years7406,489
10.91 Years and Older1301,047
15.Total3,835 31,847
Admissions By Source Of Referral
Line
No.		Source Of Referral(1)
Admissions
21.Another Home Health Agency8
22.Clinic76
23.Family / Friend0
24.Hospice0
25.Hospital (Discharge Planner, etc.)2,678
26.Local Health Department0
27.Long Term Care Facility (SN / IC)320
28.MSSP0
29.Payer (Insurance, HMO, etc.)0
30.Physician1,352
31.Self0
32.Social Service Agency4
34.Other0
35.Total4,438
Discharges By Reasons
Line
No.		Reason for Discharge(1)
Discharges
41.Admitted to Hospital290
42.Admitted to SN / IC Facility54
43.Death49
44.Family / Friends Assumed Responsibility393
45.Lack of Funds0
46.Lack of Progress12
47.No Further Home Health Care Needed2,960
48.Patient Moved out of Area17
49.Patient Refused Service37
50.Physician Request2
51.Transferred to Another HHA9
52.Transferred to Home Care (Personal Care)6
53.Transferred to Hospice68
54.Transferred to Outpatient Rehabilitation397
59.Other9
60.Total4,303
Visits By Type Of Staff
Line
No.		Type of Staff(1)
Visits
71.Home Health Aide3,523
72.Nutritionist (Diet Counseling)0
73.Occupational Therapist1,196
74.Physical Therapist5,363
75.Physician20
76.Skilled Nursing20,406
77.Social Worker930
78.Speech Pathologist / Audiologist409
79.Spiritual and Pastoral Care0
84.Other0
85.Total31,847
Visits By Primary Source Of Payment
Line
No.		Source Of Payment(1)
Visits
91.Medicare22,472
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)9,375
100.Total31,847
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		65538
2.HIV infections042110
3.Malignant neoplasms: Lung162.0 - 162.9
197.0, 231.2		39210
4.Malignant neoplasms: Breast174.0 - 174.9
175.0 - 175.9
198.2, 198.81, 233.0		18120
5.Malignant neoplasms: Intestines152.0 - 154.8
159.0,  197.4,  197.5,  197.8
198.89, 230.3, 230.4, 230.7		1586
6.Malignant neoplasms: All other sites, excluding those in #3, 4, 5140.0 - 208.91
230.0 - 234.9		1391,052
7.Non-malignant neoplasms: All sites210.0 - 229.9
235.0 - 238.9
239.0 - 239.9		1090
8.Diabetes mellitus250.00 - 250.931491,514
9.Endocrine, metabolic, and nutritional diseases; Immunity disorders240.0 - 246.9
251.0 - 279.9		64472
10.Diseases of blood and blood forming organs280.0 - 289.924157
11.Mental disorder290.0 - 3191062
12.Alzheimer's disease331.084334
13.Disease of nervous system and sense organs320.0 - 330.9
331.11 - 389.9		113746
14.Diseases of cardiovascular system391.0 - 392.0
393 - 402.91
404.00 - 429.9		4652,486
15.Diseases of cerebrovascular system430 - 438.92301,760
16.Diseases of all other circulatory system390,  392.9
403.00 - 403.91
440.0 - 459.9		99765
17.Diseases of respiratory system460 - 519.92712,342
18.Diseases of digestive system520.0 - 579.91591,179
19.Diseases of genitourinary system580.0 - 608.9
614.0 - 629.9		1391,364
20.Diseases of breast610.0 - 611.9233
21.Complications of pregnancy, childbirth, and the puerperium630 - 6772950
22.Diseases of skin and subcutaneous tissue680.0 - 709.92472,530
23.Diseases of musculosketal system and connective tissue (include pathological fx, malunion fx, and nonunion fx)710.00 - 739.98414,162
24.Congenital anormalies and perinatal conditions (include birth fractures)740.0 - 779.975121
25.Symptoms, signs, and ill-defined conditions (exclude HIV positive test)780.01 - 795.6
795.79
796.0 - 799.9		2951,627
26.Fractures (exclude birth fx, pathological fx, malunion fx, nonunion fx)800.00 - 829.12821,682
27.All other injuries830.0 - 959.94994,462
28.Poisonings and adverse effects of external causes960.0 - 995.9433
29.Complications of surgical and medical care996.00 - 999.9921,397
30.Health services related to reproduction and developmentV20.0 - V26.9
V28.0 - V29.9		34
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		34
33.Other health services for specific procedures and aftercareV50.0 - V58.983484
34.Visits for Evaluation and AssessmentV60.0 - V84.811
45.Total4,54931,847
* 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.HIV042110
52.Alzheimer's Disease331.088351
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.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 patients770
2.Survivors of persons not receiving hospice care148
Volunteer Services
Line
No.		Volunteer Services(1)
No. of Volunteers		(2)
Volunteer Hours
3.Patient / Family Services161,907
4.Bereavement1211
5.Administrative41,403
6.Medicare Reportable Hours
(sum lines 3-5)		3,521
7.Fundraising00
9.Other00
10.Total213,521
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 - RN11,218
22.Nursing - LVN1,829
23.Social Services2,348
24.Hospice Physician Services1,634
25.Homemaker and Home Health Aide9,713
26.Chaplain1,097
29.Other Clinical Services13
30.Total27,852
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 Years1001
2.2 - 5 Years0101
3.6 - 10 Years0000
4.11 - 20 Years4408
5.21 - 30 Years1304
6.31 - 40 Years47011
7.41 - 50 Years3022052
8.51 - 60 Years62740136
9.61 - 70 Years104990203
10.71 - 80 Years1391130252
11.81 - 90 Years1101270237
12.91 + Years1133044
15.Total4664830949
Unduplicated Hospice Patients By Gender and Race
Line
No.		Race(1)
Male		(2)
Female		(3)
Other / Unknown		(4)
Total
21.White3703870757
22.Black3750087
23.Native American0000
24.Asian / Pacific Islander68014
25.Other / Unknown5338091
30.Total4664830949
Unduplicated Hospice Patients By Gender And Ethnicity
Line
No.		Ethnicity(1)
Male		(2)
Female		(3)
Other / Unknown		(4)
Total
31.Hispanic101700171
32.Non-Hispanic3654130778
33.Unknown0000
35.Total4664830949
Hospice Patient Admissions By Source Of Referral
Line
No.		Source of Referral(1)
Patients
41.Home Health Agency0
42.Hospital (Discharge Planner, etc.)329
43.Long-Term Care Facility1
44.Other Hospice0
45.Payer (Insure, HMO,etc.)0
46.Physician468
47.RCFE / ARFCLHF0
48.Self / Family / Friend0
49.Social Service Agency1
54.Other0
55.Total799
Hospice Patient Discharges By Reason
Line
No.		Reason for Discharge(1)
Patients
61.Death715
62.Patient Moved Out of Area12
63.Patient Refused Service11
64.Transferred to Another Local Hospice0
65.Prognosis Extended1
66.Patient Desired Curative Treatment0
69.Other50
70.Total789
Hospice Patients Discharged By Length Of Stay
Line
No.		Length of Stay
(Days)		(1)
Patients
71.0-5 Days132
72.6-10 Days82
73.11-15 Days50
74.16-20 Days58
75.21-30 Days74
76.31-60 Days134
77.61-90 Days72
78.91-120 Days31
79.121-150 Days27
80.151-180 Days18
84.181 + Days111
85.Total789
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 Angeles68610
92.Riverside28926521602
93.San Bernardino50444253337
94.00000
95.00000
96.00000
97.00000
98.00000
99.00000
100.Total79971580949
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		2444,8769,810
2.Heart391.0 - 392.0
393 - 402.91
404.0 - 404.9 with fifth digit 1 or 3
410.00 - 429.9		24516816
3.Dementia and Cerebral Degeneration290.0 - 294.9
331.0-331.9		30650949
4.Lung, excluding cancer460 - 519.912501924
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		7100156
6.Liver, excluding cancer570 - 573.9674104
7.HIV042112
8.Brain Stroke and late effects430 - 436
438.0 - 438.9
997.02		4138200
9.Coma, with or without brain injury780.01 - 780.09
850.4
851.0 - 854.1 with fifth digit 5		000
10.Diabetes250.00 - 250.93157
11.ALS*335.20471126
19.OtherAll other codes that are not in lines 1-11.45620,19544,437
20.Total78927,12757,531
* 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.Medicare68741,656212140042,008
2.Medi-Cal000000
3.Medi-Cal Managed Care000000
4.Managed Care000000
5.Private Insurance000000
6.Self Pay000000
7.Charity000000
9.Other*30924,9896226025,077
10.Total99666,645274166067,085
* 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.Home65,0190065,019
22.Hospital014014
23.SNF02601660426
24.CLHF00000
25.RCFE / ARF1,626001,626
29.Other00000
30.Total66,645274166067,085
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
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$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 Costs$0
56.Fundraising$0
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
101.Medicare$0
102.Medi-Cal (Excluding Room and Board)$0
103.Medi-Cal Managed Care (Excluding 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 Gross Patient Revenue (sum of lines 101 through 109)$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 110 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
151.General Service Cost Centers$0
152.Inpatient Care Service$0
153.Nursing Home$0
154.Program Supervision$0
155.Visiting Services$0
156.Hospice Service Cost Centers$0
157.Other Hospice Costs$0
159.Other Costs$0
160.Total Operating Expenses (sum of lines 151 through 159)$0
165.Net from Operations (line 145 minus line 160)$0
170.Income Tax$0
175.Net Income (line 165 minus line 170)$0
General Comments:
Errors and Warnings