Annual Utilization Report of Home Health Agencies / Hospices
Facility Name:TAHOE FOREST HOSPICE
OSHPD ID:406294011Report Status:Submitted
License Category:HospiceReport Year:2002
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:TAHOE FOREST HOSPICE
2.OSHPD ID Number:406294011
3.Street Address:10083 LAKE AVENUE
4.City:TRUCKEE
5.Zip:96161
6.Facility Phone No.:( 530) 582 - 3534 ext.
7.Administrator Name:Robert Schapper
8.Administrator E-mail Address:rschapper@tfhd.com
9.Was this agency in operation at any time during the year?:Yes
10.Operation Open From:01/01/2002
11.Operation Open To:12/31/2002
12.Name of Parent Corporation:
13.Corporate Business Address:
14.City:
15.State:
16.Zip:-
17.Person Completing Report:Eileen Knudson
18.Phone No.:530-582-3534
19.Fax No.:530-582-6278
20.E-mail Address:eknudson@tfhd.com
25.Entity Type:Hospice Only
26.Entity RelationSole Facility
30.Submitted by:406294011
31.Submitted Date and Time:11/25/2003 1:57:10 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.Do you have a Registered Nurse on staff who makes home visits?Unspecified
16.Is your agency a licensed Pharmacy?Unspecified
Note: If the agency is a licensed pharmacy that provides only home infusion therapy equipment then there is no need to complete the remainder of the report
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?Select Yes or 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 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, 045.0-139.800
2.HIV infections (include AIDS, ARC, HIV)04200
3.Malignant neoplasms: Lung162.0-162.9, 197.0, 231.200
4.Malignant neoplasms: Breast174.1-174.9, 175.0-175.9, 198.2, 198.81, 233.000
5.Malignant neoplasms: Intestines152.0-154.8, 159.0, 197.4, 197.5, 197.8, 198.89, 230.3, 230.4, 230.700
6.Malignant neoplasms: All other sites, excluding those in #3, 4, 5140.0-208.91, 230.0-234.900
7.Non-malignant neoplasms: All sites210.0-229.9, 235.0-238.9, 239.0-239.900
8.Diabetes mellitus250.00-250.9300
9.Endocrine, metabolic, and nutritional diseases; Immunity disorders240.0-246.9, 251.0-279.900
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, 331.1-389.900
14.Diseases of cardiovascular system391.0-392.0, 393-402.91, 404.00-429.900
15.Diseases of cerebrovascular system430-438.900
16.Diseases of all other circulatory system390, 392.9, 403.00-403.91, 440.0-459.900
17.Diseases of respiratory system460-519.900
18.Diseases of digestive system520.0-579.900
19.Diseases of genitourinary system580.0-608.9, 614.0-629.900
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, 795.77, 796.0-799.900
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-V29.900
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, V39.200
32.Health hazards related to communicable diseasesV01.0-V19.8, V40.0-V49.900
33.Other health services for specific procedures and aftercareV50.0-V58.900
34.Visits for Evaluation and AssessmentV60.0-V83.8900
45.Total00
* The list of ICD-9-CM codes excluded: 795.71, V08, V27.0-V27.9
How many of the patients you reported in Section 3 "Patients and Visits by Age"Table had a primary or secondary diagnosis of HIV or Alzheimer's Disease and how many health care visits were made to them? The primary condition for which an HIV or Alzheimer's patient was visited may have been a fracture, a skin infection, cancer, or any number of primary conditions. 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 primary condition 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:District
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.Primarily Rural
Section 6 - Hospice Services
Bereavement Services
Line
No.		Bereavement Services(1)
People Served
1.Survivors of hospice patients146
2.Survivors of persons not receiving hospice care60
Volunteer Services
Line
No.		Volunteer Services(1)
No. of Volunteers		(2)
Volunteer Hours
3.Patient / Family Services401,441
4.Bereavement00
5.Administrative4619
6.Medicare Reportable Hours
(sum lines 3-5)		2,060
7.Fundraising00
9.Other00
10.Total442,060
Additional And Specialized Services
Check all services directly 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 - RN1,487
22.Nursing - LVN0
23.Social Services232
24.Hospice Physician Services8
25.Homemaker and Home Health Aide727
26.Chaplain13
29.Other Clinical Services52
30.Total2,519
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 Years1102
7.41 - 50 Years3306
8.51 - 60 Years37010
9.61 - 70 Years97016
10.71 - 80 Years1310023
11.81 - 90 Years915024
12.91 + Years2204
15.Total4145086
Unduplicated Hospice Patients By Gender and Race
Line
No.		Race(1)
Male		(2)
Female		(3)
Other / Unknown		(4)
Total
21.White4044084
22.Black0000
23.Native American1001
24.Asian / Pacific Islander0101
25.Other / Unknown0000
30.Total4145086
Unduplicated Hospice Patients By Gender And Ethnicity
Line
No.		Ethnicity(1)
Male		(2)
Female		(3)
Other / Unknown		(4)
Total
31.Hispanic1001
32.Non-Hispanic4045085
33.Unknown0000
35.Total4145086
Hospice Patient Admissions By Source Of Referral
Line
No.		Source of Referral(1)
Patients
41.Home Health Agency9
42.Hospital (Discharge Planner, etc.)10
43.Long-Term Care Facility0
44.Other Hospice3
45.Payer (Insure, HMO,etc.)0
46.Physician30
47.RCFE / ARFCLHF0
48.Self / Family / Friend22
49.Social Service Agency0
54.Other3
55.Total77
Hospice Patient Discharges By Reason
Line
No.		Reason for Discharge(1)
Patients
61.Death69
62.Patient Moved Out of Area1
63.Patient Refused Service0
64.Transferred to Another Local Hospice0
65.Prognosis Extended2
66.Patient Desired Curative Treatment0
69.Other1
70.Total73
Hospice Patients Discharged By Length Of Stay
Line
No.		Length of Stay
(Days)		(1)
Patients
71.0-5 Days16
72.6-10 Days6
73.11-15 Days7
74.16-20 Days5
75.21-30 Days11
76.31-60 Days11
77.61-90 Days8
78.91-120 Days2
79.121-150 Days2
80.151-180 Days0
84.181 + Days5
85.Total73
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.Nevada3231137
92.Plumas1715221
93.Sierra8708
94.Placer1915119
95.El Dorado1101
96.00000
97.00000
98.00000
99.00000
100.Total7769486
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, 230.0-234.9511,5362,649
2.Heart391.0-392.0, 393-402.91, 404.0-404.9 with fifth digit 1 or 3, 410.00-429.9670120
3.Dementia and Cerebral Degeneration290.0-294.9, 331.1-331.922935
4.Lung, excluding cancer460-519.953969
5.Kidney, excluding cancer580.0-589.9, 403.00-403.93, 404.0-404.9 with fifth digit 2 or 3, 405.0-405.9 with fifth digit 1134
6.Liver, excluding cancer570-573.912937
7.HIV042000
8.Brain Stroke and late effects430-436, 438.0-438.9, 997.024311407
9.Coma, with or without brain injury780.01-780.09, 850.4, 851.x5, 852.x5, 583.x5, 854.x5000
10.Diabetes250.00-250.93000
11.ALS*335.20000
19.OtherAll other codes that are not in lines 1-11.352112
20.Total732,0693,433
* 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.Medicare633,714174303,774
2.Medi-Cal8274000274
3.Medi-Cal Managed Care000000
4.Managed Care000000
5.Private Insurance14933500938
6.Self Pay000000
7.Charity000000
9.Other*14900049
10.Total864,970224305,035
* 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.Home4,970004,970
22.Hospital0224365
23.SNF00000
24.CLHF00000
25.RCFE / ARF0000
29.Other00000
30.Total4,970224305,035
Section 10 - Hospice Income and Expenses Statement
Detail Of Operating Expenses
Where indicated, use data from Medicare Cost Report Worksheet A Column 10 and Lines as listed
Line
No.		(1)
Total		Medicare Cost Report Worksheet A, Column 10
General Service Cost Centers
30.Administrative and General$234,100Sum of Lines 1-6
Inpatient Care Service
31.Inpatient - General Care$0Line 10
32.Inpatient - Respite Care$0Line 11
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$14,400Line 15
37.Nursing Care$260,700Line 16
38.Rehabilitation Services (PT, OT, Speech)$2,040Sum of Lines 17, 18, and 19
39.Medical Social Services - Direct$58,600Line 20
40.Spiritual Counseling$1,200Line 21
41.Dietary Counseling$2,100Line 22
42.Counseling - Other$12,000Line 23
43.Home Health Aides and Homemakers$28,000Line 24
44.Other Visiting Services$0Line 25
Hospice Service Cost Centers
45.Drugs, Biologicals and Infusion$65,000Line 30
46.Durable Medical Equipment / Oxygen$72,000Line 31
47.Patient Transportation$0Line 32
48.Imaging, Lab and Diagnostics$18,000Sum of Lines 33 and 34
49.Medical Supplies$12,000Line 35
50.Outpatient Services (including ER Dept.)$0Line 36
51.Radiation Therapy$5,000Line 37
52.Chemotherapy$2,500Line 38
53.Other Hospice Service Costs$24,000Line 39
Other Hospice Costs
54.Bereavement Program Costs$2,500Line 50
55.Volunteer Program Costs$15,750Line 51
56.Fundraising$5,000Line 52
Other Costs
57.Other Program Costs*$232,000Line 53 plus any other costs
59.Total Operating Expenses$1,066,890
* Program costs including community education and outreach program costs.
Hospice Income Statement
Line
No.		(1)
Total
Gross Patient Revenue
101.Medicare$519,960
102.Medi-Cal (Excluding Room and Board)$38,360
103.Medi-Cal Managed Care (Excluding Roam and Board)$0
104.Managed Care (Non Medi-Cal)$0
105.Private Insurance$130,620
106.Self-Pay$0
109.Other Payers$5,000
110.Total Gross Patient Revenue (sum of lines 101 through 109)$693,940
Write-Offs and Adjustments
111.Contractual Adjustments$137,416
112.Denials / Bad Debt$15,000
113.Charity$5,000
119.Other Write-offs and Adjustments$0
120.Total Write-Offs and Adjustments (sum of lines 111 through 119)$157,416
125.Net Patient Revenue (line 110 minus line 120)$536,524
Other Operating Revenue
131.Grants$6,000
132.Donations / Contributions$50,000
133.Unrelated Business Income$0
139.Other$336,000
140.Total Other Operating Revenue (sum of lines 131 through 139)$392,000
145.Total Operating Revenue (line 125 plus line 140)$928,524
Operating Expenses
151.General Service Cost Centers$234,100
152.Inpatient Care Service$0
153.Nursing Home$0
154.Program Supervision$0
155.Visiting Services$379,040
156.Hospice Service Cost Centers$198,500
157.Other Hospice Costs$23,250
159.Other Costs$232,000
160.Total Operating Expenses (sum of lines 151 through 159)$1,066,890
165.Net from Operations (line 145 minus line 160)-$138,366
170.Income Tax$0
175.Net Income (line 165 minus line 170)-$138,366
General Comments:
Our Hospice is located in California, close to the Nevada state line. We have a California and a Nevada state license and service patients in Plumas, Placer, Eldorado, Sierra, Nevada, and Washoe County. I spoke with Ken Winn (916 322-1774) at the California state report help desk and he suggested we combine our statisticcs for Washoe County, Nevada in with Nevada County, California. Washoe County is not listed as an option on the pull-down menu.
Errors and Warnings